A 29-year-old man was hospitalized for headache, confusion, and fever of up to 40.3°C, of 3 days' evolution. His medical history had recorded that he was a tobacco and cannabis smoker and parenteral drug user (heroin and cocaine), and had chronic liver disease due to hepatitis C virus infection. On physical examination, the patient was found to be somnolent and disoriented; the remaining examination was unremarkable. Laboratory analyses disclosed elevated transaminases and leukocytosis of 32´109 with neutrophilia. The electrocardiogram, cranial computed tomography scan, and chest radiograph were normal, but lumbar puncture showed acute inflammatory cerebrospinal fluid. The suspected diagnosis was herpes encephalitis; however, Staphylococcus aureus was isolated in 2 blood cultures. The transthoracic echocardiogram was normal, but transesophageal echocardiography detected mitral endocarditis. A 3´3-mm diameter mobile vegetation was attached to the base of the atrial surface of the posterior mitral leaflet, which was perforated and caused mild mitral regurgitation.

The patient was stable and afebrile on antibiotic treatment while awaiting valve surgery, when he presented sudden electromechanical dissociation and died. The autopsy showed cardiac tamponade caused by a hemopericardium (Figure 1) and endocarditis of the posterior mitral leaf, which was perforated and complicated by a perivalvular myocardial abscess that was fistulized to the pericardial cavity (Figures 2 and 3 [detail]). Inactive chronic liver disease was also found.

Figure 1.

Figure 2.

Figure 3.

Sudden death caused by a massive hemopericardium and cardiac tamponade secondary to a fistulized myocardial abscess is an extremely uncommon, fatal complication of infectious endocarditis.

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