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An 18-year-old man presented with a 3-day history of malaise, pyrexia, confusion and left knee pain. He had a history of atopic eczema since the age of 6 months but was otherwise well. He had worn a dental brace for the past 2 years without complications and had no recent dental intervention. There was no history of intravenous drug abuse. On examination he was pyrexial at 39.0°C, clinically dehydrated, with a sinus tachycardia of 100 beats per minute and a systemic blood pressure of 130/80 mmHg. He had eczematous lesions on his face, arms and legs. Auscultation revealed no cardiac murmurs and lung fields were clear. There were no stigmata of endocarditis. He was mentally obtunded with a Glasgow Coma Score of 14/15 but had no other neurological signs. The left knee demonstrated a full range of movement and no obvious effusion. Orthopaedic opinion was of a reactive arthritis.Chest and left knee radiography was unremarkable. C-reactive protein (CRP) was elevated at 251mg/litre, haemoglobin was 12.4g/dl, leukocytes 11.7×109/litre (with 89% neutrophils) and platelets 26×109/litre. A screen for disseminated intravascular coagulopathy was negative. He was hyponatraemic (sodium 125 mmol/litre) and mildly uraemic (urea 7.8 mmol/litre, creatinine 91μmol/litre).Blood cultures grew Staphylococcus aureus sensitive to flucloxacillin and gentamicin. Computed tomography (CT) of the brain showed generalized cerebral swelling with effacement of the basal cisterns, but no focal abnormality. Treatment was initiated with intravenous flucloxacillin, gentamicin and fluid replacement.The following day he developed severe pulmonary oedema and haemodynamic compromise necessitating admission to the intensive care unit for inotropic support and ventilation. Urgent transoesophageal echocardiography showed a 2x2 cm vegetation on the anterior mitral valve leaflet (Figure 1) with marked prolapse and severe mitral regurgitation. There was systolic flow reversal in the pulmonary veins. Left atrial size was normal and left ventricular function good.He underwent emergency mitral valve replacement with a St Jude mechanical valve (St Jude Medical Inc, St Paul, Minnesota, USA). At operation there was seen to be almost complete destruction of the anterior mitral valve leaflet. His postoperative recovery was good, completing 6 weeks of antibiotic therapy, and repeat CT showed resolution of the cerebral oedema. During the admission he experienced an exacerbation of his eczema and was treated with topical steroids and emollients by the dermatologists.