A previously healthy 14 year old girl presented with a three week history of high grade fever and progressive dyspnoea. On admission to the hospital in Mozambique, she had signs of cardiac insufficiency with peripheral oedema, orthopnoea, and tachycardia. The chest x ray on admission demonstrated massive lung oedema and cardiomegaly, and the ECG revealed a right bundle branch block and a strain pattern. Because of limited resources no laboratory work up could be done, and no microorganism could be isolated. The transthoracic echocardiogram showed destruction of the aortic valve with massive aortic regurgitation and two periaortal abscess cavities (below left, parasternal long axis view, arrow indicates abscess cavities). The left ventricle was dilated with severely reduced systolic function. The patient was treated with ampicillin, gentamicin, oxacillin, digoxin, and diuretics. She initially responded well with symptom improvement, but after about 14 days her clinical status worsened. Echocardiography now showed an increase of the abscess formation that also appeared midseptal (below centre, parasternal long axis view, and below right, parasternal short axis view midseptal). Because of lack of treatment options (there is no cardiac surgery available in Mozambique) and the ongoing deterioration of the patient, the parents took the girl home where she presumably died.
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