A 42-year-old man with a 2-month history of low-grade fever treated with antibiotics, fatigue and asthenia was admitted to our hospital because of left heart failure and a pan-systolic murmur audible in the mitral area. The patient had anaemia (8.3 g/dL), with an elevated erythrocyte sedimentation rate (54 mm/h) and leucocytosis (15,000/mm 3 ). Subsequent blood cultures were negative but blood serology could not be performed. Transthoracic and transoesophageal echocardiography demonstrated severe aortic regurgitation ( Fig. 1 ) and an anterior mitral valve leaflet aneurysm with associated leaflet perforation ( Fig. 2 ). Doppler examination revealed severe mitral regurgitation across the mitral valve aneurysm. The site of anterior mitral valve leaflet perforation corresponded to the point of impact of the aortic regurgitation jet on the leaflet. The aortic valve was thickened but no signs of endocarditis were found. A computed tomography scan could not be performed for technical reasons. The patient refused surgery for religious reasons.
