1276 Editorial between late acquired ISA and long term adverse outcomes requires further analysis’. Conﬂict of interest: none declared. 5. References 1. Siqueira DA, Abizaid AA, de Ribamar Costa J, Feres F, Abizaid A, Mattos LA, Staica R, Abizaid AA, Tanajura LF, Chaves A, Centemero M, Sousa AGMR, Sousa JEMR. Late incomplete apposition after drug-eluting stent implantation: incidence and potential for adverse clinical outcomes. Eur Heart J 2007;28:1304–1309. First published on May 3, 2007, doi:10.1093/eurheartj/ehm114. 2. Ako J, Morino Y, Honda Y, Hassan A, Sonoda S, Yock PG, Leon MB, Moses JW, Bonneau HN, Fitzgerald PJ. Late incomplete stent apposition after sirolimus-eluting stent implantation: a serial intravascular ultrasound analysis. J Am Coll Cardiol 2006;46:1002–1005. 3. Degertekin M, Regar E, Tanabe K, Lemos P, Lee CH, Smits P, de Feyter P, Bruining N, Sousa E, Abizaid A, Ligthart J, Serruys PW. 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Donnelly2, and Daniel J. Flannery1 Cardiology Department, Craigavon Area Hospital, 68 Lurgan Road, Portadown, BT63 5QQ, UK and 2Belfast City Hospital, 51 Lisburn Road, Belfast, BT9 7AB, UK; 1 *Corresponding author. Tel: þ44 2838334444; fax: þ44 2838394802. E-mail address: [email protected] A 57-year-old male was admitted with a 2-week history of fever, rigours, and confusion and a single episode of retrosternal chest pain. He had recently undergone a circumcision. Clinical examination revealed a temperature of 38.38C and a balanitis. Urinanalysis revealed haematuria and proteinuria. He had acute renal failure (urea 24.5 mmol/L, creatinine 341 mmol/L) and an elevated Creactive protein (356 mg/L). Twelve-lead electrocardiograph demonstrated anterolateral T-wave inversion and troponin T was elevated (0.176 ng/mL), suggesting an acute coronary syndrome. Ultrasound of renal tracts was normal. Group B haemolytic Streptococcus was isolated from both blood cultures and from swabs of his balanitis. Trans-thoracic and trans-oesophageal echocardiography demonstrated normal left-ventricular systolic function and an echo dense irregular mass at the apex of the left ventricle (Panel A) but no valvular abnormality. Computed tomography (CT) of brain revealed an infarct adjacent to the right caudate nucleus (Panel B). A radiolabelled isotope white cell scan demonstrated focal uptake at the apex of the left ventricle (Panel C). A diagnosis of mural endocarditis with coronary and cerebral embolization was made. Despite appropriate antibiotic therapy, a left ventricular apical myomectomy was required because of his continuing clinical deterioration. Surgical excision and pathological examination conﬁrmed this rare occurrence. Mural endocarditis in the absence of pre-disposing factors is extremely rare. This condition is usually fatal; however, our patient was fortunate to survive and make a full recovery. Panel A. Echocardiogram demonstrating apical vegetation. LV, left ventricle; RV, right ventricle. Panel B. CT scan of brain demonstrating an infarct adjacent to the right caudate nucleus. Panel C. Radioisotope-labelled white cell scan with focal uptake at the apex of the left ventricle. Downloaded from by guest on November 7, 2014 Clinical vignette