A 45 years old gentleman with good past health developed on-and-off fever, malaise, bilateral lower limb rash, shortness of breath and palpitation for two weeks. Physical examination showed purpuric skin rash over both lower limbs. The cardiovascular examination showed a pansystolic murmur, best heard at the apex. Bedside echocardiography was performed in the emergency department and revealed vegetation over the mitral valve leaflet with severe mitral regurgitation. He was admitted to the medical ward with a provisional diagnosis of infective endocarditis and subsequently received a mitral valve replacement.
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