PMC4677589_01
(a) EKG on admission with an old incomplete left bundle branch block, (b) EKG showing second-degree AV block (2:1) - Mobitz type II and (c) EKG showing ventricular pacing.
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EKG initially showed an old incomplete left bundle branch block (Fig. 1a); chest X-ray was normal and lumbar spine X-ray revealed degenerative disc disease with suspected discitis and spinal stenosis noted significantly at L3-L4, L4-L5, and L5-S1. A repeat EKG revealed Mobitz type II atrioventricular block (Fig. 1b). Antibiotic therapy was continued with continuous cardiac monitoring; however, due to persistent symptomatic bradycardia, epicardial pacing was done (see Fig. 1c).
(a, b) MRI of the lumbosacral spine showing a prominent marrow edema pattern adjacent to the L3-L4 and L5-S1 suggestive of osteomyelitis/discitis (see arrows): (a) coronal T1-weighted image and (b) sagittal T1-weighted image.
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MRI of the spine revealed L3-L4 and L5-S1 disc endplate changes with significant marrow edema suggestive of discitis and vertebral osteomyelitis (Fig. 2a and b).
Three-phase bone scan showing focal abnormal radiotracer accumulation at the L3-L4 and L5-S1 intervertebral disc level suspicious for osteomyelitis/discitis.
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Three-phase bone scan also showed increased uptake at L3-L4 and L5-S1 (Fig. 3).
Transthoracic echocardiogram (four-chamber view) showing vegetation on tricuspid valve (see arrow).
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Because of the presence of low-grade fever and a new murmur, transthoracic echocardiogram was done which showed tricuspid vegetation with moderate tricuspid regurgitation (Fig. 4).
(a, b, and c) Transesophageal echocardiogram showing large vegetation on tricuspid valve (see arrows). No paravalvular complications visualized.
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TEE revealed large fixed vegetation measuring 27x16 mm2 on the right atrial aspect of the tricuspid valve but no valve ring or septal abscess (Fig. 5a-c).