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A 53-year-old man, with no medical history, presented to the emergency department with malaise and severe shortness of breath two months after a dog bite. On physical examination, the heart rate was 95 beats per minute, blood pressure was 128/48 mm Hg and a cardiac decrescendo diastolic murmur as well as a Duroziez sign were noted. Laboratory tests showed elevated infection parameters (C-reactive protein [CRP] 105 mg/l, leucocytes 22.5 10^9/l), liver enzymes and N‑terminal pro-brain natriuretic peptide (NT-pro-BNP: 3532 pg/ml). Echocardiography revealed a large vegetation on the aortic valve with severe regurgitation (Fig. 1a). A colour M‑mode Doppler imaging of the transmitral flow is shown (Fig. 1b). What is your diagnosis?
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M.A.W. Habets and S. Bouwmeester declare that they have no competing interests.
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M. A. W. Habets