CASE # 1
A 6 year old Beagle was attacked by a coyote six months ago. Surgery was done at the time to repair body wall wounds, and various punctures to the small intestines. After several weeks, the owner noticed episodes of what looked to be pain. The patient would actually wake up from a sleep and cry out, and assume “the position of relief” (if you don’t know what this is, Google it). Sometimes, there was vomiting, and sometimes there was pain after eating. An abdominal ultrasound was requested to see if the cause of the pain could be identified.
Here is an ultrasound image of what was found. An abnormally corrugated small intestinal loop, with some small pockets of fluid in the wall. It was hard to picture how this could be secondary to the prior coyote bite wounds, but what else could it be from? The rest of the abdomen appeared normal, so this had to be the cause of the pain.
A surgical exploration was done, and this abnormal section of small intestine was removed. The picture shows the small fluid pockets of the intestinal wall, and the abnormal corrugation.
Following surgery, the patient has not shown any signs of pain. We don’t know why this occurred, and why the intestines would not heal properly. Also, we don’t know why it took weeks after the initial repair to start causing problems. What we do know is that the abdominal ultrasound study helped identify the problem, so that the proper treatment could be recommended.
CASE # 2
For 2 months, this dog had been sneezing and had red tinged drainage from his nostrils. Antibiotics and steroids did not seem to help. We were called in by the referring veterinarian to do a rhinoscopy. This procedure revealed a large grass awn in the nasopharynx. The grass awn was grasped with forceps and removed in 1 piece. The rest of the nasal cavity was thoroughly examined to ensure that there were no more pieces present. As you can imagine, this cured this pet’s signs!
CASE # 3
How many rocks does it take for a dog to get sick? It can vary, but we were able to remove 15 of them using endoscopy from this dog. Don't you wonder what makes them think, yum, this rock tastes delicious, I'm going to eat just one more?
CASE # 4
Here is a lateral radiograph (x-ray) from a 1 year old dog who was seen to have eaten his mini tennis ball while playing. He had been vomiting ever since. Luckily, the veterinarian thought to call us to have it removed. Otherwise, he would have had to have surgery.
The second picture shows the ball after it was taken out using the endoscope. This is so much less traumatic for the dog. He was able to go home and be normal afterwards. No invasive surgery needed. The cost is less, and the recovery rapid, and the complication rate much less than surgical exploration.
Chest radiographs from this large dog (presented for 3 weeks of drooling, not feeling well, anorexia, and 7-pound weight loss) revealed an enlarged hilar lymph node; in Phoenix, this is often seen with Valley Fever (a fungal infection caused by the organism Coccidioides immitis). A possible abdominal mass was also suspected, due to some intestinal displacement seen. On a thoracic ultrasound, an enlarged hilar lymph node was visible above the left atrium of the heart. There was also an increased amount of pleural fluid. A sample of pleural fluid was taken and sent out to the lab to be evaluated. The lab results came back showing that the problem was a tumor, specifically a round cell tumor. Attached is an image of the cells found (sent by the lab). There were also inflammatory cells. Also attached are images of the radiographs showing the enlarged hilar lymph node. The moral of the story……Don’t count your chickens before they hatch…..No, the moral really is: Don’t assume the most frequent cause of disease is always the cause. One needs to take samples from patients to get a definitive diagnosis.
This Golden Retriever had crusting of the right nostril for about 2 years. He was reportedly panting more than the other dogs in the household. He had been on therapy with antihistamines and prednisone, but this had not helped. Rhinoscopy was done, which revealed two nasal mites in the right nasal cavity, along with a mild increase in the amount of stringy mucus. No mites were found in the entire left nasal cavity, which appeared normal. The patient was treated with an appropriate medication to kill the nasal mites and resolve the problem.
This is a challenging case to know what to do. This adult Chihuahua had a large mass in the inguinal area. It was thought to be a fatty tumor (lipoma), but radiographs revealed that the mass was actually an inguinal hernia, and most of the intestines had translocated into the hernia (note the arrows on the second lateral radiograph). What is not so obvious is that the radiographs also show an enlarged, irregularly shaped heart. This is outlined with arrows on the 3rd radiograph. Soon after he was positioned for the VD radiographic view, he became cyanotic, with labored breathing. A cardiac ultrasound was therefore done to further evaluate the heart. The ultrasound study showed mitral endocardiosis with mitral regurgitation, and a large, solid, hypoechoic mass off the aortic arch, at the base of the heart. The heart base tumor is most likely a chemodectoma (aortic body tumor). This tumor is not surgically resectable. It has probably been there a long time, and it may be a long time before it causes a pericardial effusion and resultant clinical signs. What would you do? The decision was to start appropriate cardiac medications for the mitral regurgitation, and to then surgically correct the inguinal hernia. The owners felt that their pet had no signs of the heart problem, but was having problems with the hernia. We will see how long it takes before the heart base mass starts to cause clinical signs. I have followed some dogs for years with this type of lesion, with no signs developing. Let’s hope this occurs in this patient.
This adult Standard Poodle had chest radiographs that revealed an esophageal foreign body as the cause of persistently bringing up his food. The owners mentioned that the pet had eaten some meat off the counter the previous night. Since it is very important to remove esophageal foreign bodies as soon as possible, the owners agreed to have an emergency esophagoscopy performed after hours. During the esophagoscopy, a large piece of meat was found lodged in the esophagus, and it was successfully removed with an endoscopic grasping forceps. Some areas of the esophageal mucosa were black and were starting to become necrotic, but there were no ulcerations yet. It is hoped that the esophagus can now heal, without forming a stricture (a possible complication when the lining of the esophagus is damaged, as in this case).
This adult male Dachshund was presented for chronic sneezing. There had been minimal nasal discharge. Dental radiographs were normal. A dentistry was done, but the signs persisted. A rhinoscopy was performed to evaluate the nasal cavities. Just inside the left nostril, there was an abnormal white and black structure. Can you figure out what this is? See the first image. One consideration was that it may be an imbedded pebble. During an exam of the mouth, the canine tooth in question appeared normal. See the second image. Using a dental probe, it was discovered to be an abscessed root of the left upper canine tooth that had eroded through the nasal mucosa. See the third image. After the probe was passed through the gum line, the endoscope was passed again and the probe was seen in the nasal cavity. See the fourth image. The abscessed tooth was then extracted, which should lead to resolution of the sneezing. See the fifth image.
Look what we found!!
This 3 ½ month old male kitten had a history of failure to thrive, which had progressively worsened. He was thin and had a "pot-bellied" appearance. Radiographs showed poor serosal detail, and possible liver enlargement or free-fluid in the abdomen. On palpation, abdominal pain was noted. Blood chemistry showed increased ALT (133 U/L) and decreased albumin (2.1 g/dL). A CBC showed normal WBC (15.77 K/uL), with lymphocytosis (12.43 K/uL) and eosinopenia (0.10 K/uL). There was also anemia (RBC=5.66 M/uL, HCT=18.7%), with decreased hemoglobin (6.4 g/dL) and decreased platelets (96 K/uL). FeLV and FIV tests were negative. An abdominal ultrasound showed enlargement of the liver and spleen, with marked mesenteric lymphadenopathy (see the pictures). Neoplastic or inflammatory diseases were considered most likely. An aspiration of the spleen or an enlarged lymph node was offered, to try to make a cytologic diagnosis. The owner declined further diagnostics, and the kitten was euthanized. A necropsy was performed, since the owner had other kittens from the litter. Here is a picture of the histopathology slide, which was diagnostic for a fungal disease called histoplasmosis. It’s a yeast with a capsule. This is an uncommon problem in Arizona, but can be seen in a cat from our Phoenix area. By knowing the diagnosis, the other cats in the household and litter can be screened and treated, if they are infected.
This 17-year-old, FS, cat had a history of bloody urine and straining to urinate, which has been non-responsive to antibiotics. On abdominal palpation, a firm, irregular urinary bladder was noted. We performed an ultrasound and found…….There is a large, hypoechoic, irregularly surfaced mass of the bladder wall, and an enlarged hypoechoic sublumbar lymph node. There was not much room for urine in the bladder, given the size of the mass. Hence, the straining. The mass is likely an aggressive tumor. Most likely it is a transitional cell carcinoma, but it could be some other tumor type. The enlarged sublumbar lymph node likely represents metastatic disease. The prognosis is poor. Surgery is not an option. [If you would like to see a photo of what a normal bladder looks like, you can view that in our folder for normal ultrasounds on our Facebook page]
This 2 yr old FS cat, had urinary issues similar to the other cat posted today. She was straining to urinate and there was blood in the urine. A urinalysis revealed concentrated urine with some struvite crystals. She was treated with a special urinary diet and an antibiotics for several months, but the signs persisted. The most recent urinalysis was again concentrated, but with amorphous crystals. Treatment with antibiotics and steroids did not help. Bleeding from her vulva was also reported by her owner despite the fact that she was spayed. An ultrasound revealed... multiple bladder stones and bilateral renal calcifications. Since she had been on the urinary diet and the stones obviously had not dissolved, surgery was recommended to have them removed. The same signs as the other cat posted, but different findings!
This 12 yr old Bichon/Poodle mix dog was reportedly adopted when young, as a neutered male dog. He developed hematuria (bloody urine) recently that had not been responsive to antibiotics. Cancer was a concern. An abdominal ultrasound revealed an enlarged, cystic prostate gland, with a smooth capsule. It was non-painful to palpation. The finding of benign cystic prostatic hyperplasia is only seen if testicles are present. Sure enough, with the ultrasound, bilateral retained testicles were also found in the abdomen. Surgery was needed to remove the testicles. Once removed, the prostate gland will involute, and the hematuria will resolve.
The moral of the story; when adopting a stray, one should ask the adoption agency if they actually performed the neutering surgery, or did they just assume that it was done. Interestingly, retained testicles often develop tumors within them. However, these testicles had no tumors.
These radiographs are from a 9 yr old cat that presented for a hacking cough and decreased energy level. Thoracic radiographs showed a suspect mass in the right cranial lung lobe (see the arrows on the pictures). The radiographs were submitted elsewhere for interpretation, and the report said this was likely pulmonary neoplasia. Blood work was performed approximately 2 months previously, and was within normal limits. A cardiothoracic ultrasound by PVIMS revealed….. a solid, hypoechoic mass of the right cranial lung lobe (see the ultrasound image). The ultrasound (and radiographs) cannot differentiate between a primary lung tumor, metastatic neoplasia, or a fungal granuloma. A sample has to be taken from the lesion, to look at it microscopically.
So, to get an answer, ultrasound guidance was used to obtain fine needle aspirates of the lung mass for cytology. The cytology revealed that the mass in the lung is actually a Valley Fever granuloma.
Note the large spherules (dark purple structures) on the photo of microscope slide (cytology). These spherules contain many endospores. One of the cytology pictures has a picture of an endospore. This gives you a size comparison between a spherule and an endospore. On all the slides, there are an increased number of white blood cells, which means that there is inflammation.
Antifungal therapy was started, and the lesion will be monitored over time. If you did not know, Dr Greene has done considerable research on Valley Fever, and has authored textbook chapters on the topic. He reported on the success of therapy in 48 cats over time. He can help this patient out since he has extensive experience with this disease.
This 8-yr-old Miniature Schnauzer was presented to his regular veterinarian for vomiting, lethargy, and decreased appetite. He was found to have a painful abdomen and a painful swelling near his prepuce. There was no history of diet changes, toxin exposure, or chewed or missing items in the household. The blood work was relatively normal. Radiographs showed slightly reduced abdominal serosal detail. There was also a metal pellet embedded in the ventral body wall near the midline, with some associated swelling. (see the photo of the radiograph). Also, when shaving him for the abdominal ultrasound exam, a circular wound was found on the left body wall (see the photo).
The ultrasound evaluation revealed several corrugated loops of jejunum (small intestines), and hyperechoic fat around these (see the ultrasound photos). There was a mild amount of free fluid around the abnormal jejunal loops. The metal pellet could be seen to be outside the body wall, and there was an opening in the body wall adjacent to this pellet.
Ultrasound guidance was used to aspirate some of the fluid around the jejunum. It was pus (see the photo of the stained fluid sample on the microscope slide).
From these changes, it was suspected that the pellet had recently penetrated the body wall on the left side behind the ribs (causing the circular skin lesion), entered and penetrated the adjacent jejunal loops (causing the peritonitis), and took a circuitous route to exit the body wall on the ventrum, with the metal pellet now resting under the skin near the prepuce. Surgery was recommended to flush the abdomen and evaluate any abnormal intestinal loops.
Surgery was performed later that same day. During surgery, a 10-15 cm section of abnormal jejunal loop (with penetrations) was found, and a resection and anastomosis was performed. The abdomen was flushed. The swollen area near the prepuce was explored and an abscess with the pellet was found. The pellet was removed. Supportive care with fluids and antibiotics were successfully used.
He was released a couple of days later and has been doing well at home since. Obviously, the owner will need to investigate who in the neighborhood has a pellet gun, because this was a deliberate shooting.
A 9 yr old FS German Shepard was presented for a 2-day history of increasing lethargy and weakness. She was found to have a fever (103.8°F), and possible abdominal pain was elicited on palpation. Radiographs and blood work were normal. She was given supportive care with antibiotics and medicine to control vomiting. A few days later she was presented for a follow-up visit. The owner felt that the patient was somewhat improved. On examination, her temperature was normal (101.8°F). However, repeat radiographs showed a loss of detail in the abdomen, suggesting that there may be free fluid in the abdomen (see the lateral radiograph). An ultrasound was requested.
There was a mild amount of hypercellular fluid in the abdomen. There was also a mild amount of gallbladder sludge, but the walls of the gallbladder appeared normal (see the ultrasound images). The rest of the abdomen appeared normal.
A sample of the free abdominal fluid was obtained. It was bile-colored and cloudy (see the photo). A stained slide was examined, and the fluid appeared to be packed with white blood cells (see the photo). No bacteria were seen. Peritonitis was diagnosed. The cause of the peritonitis was not determined on ultrasound, however it was suspected that the gallbladder may have ruptured. Surgery was recommended.
Surgery was done by a skilled surgeon, within 2 hours of the ultrasound procedure. A moderate amount of yellow and red fluid was flushed from the abdomen. The tip of the gallbladder was found to be necrotic (dead), and there was abnormal architecture of the quadrate lobe of the liver (infection suspected). A gallstone (1 cm diameter) was found free in the abdomen, and there was a mild degree of bile peritonitis. The gallbladder was removed, along with the gallstone that was found free in the abdomen. Approximately 90% of the quadrate liver lobe of the liver was removed, and the abdomen was flushed out.
The patient recovered from surgery and was discharged the next day, feeling great!
The importance of this case is to understand that diseases are dynamic. They change over time. The gallbladder likely had been very large before the ultrasound procedure, and it subsequently must have broken open, releasing its gallstone and bile into the abdomen. Following this rupture, there was no further pressure on the gallbladder and no gallstone within the gallbladder, to help identify the cause of the infection. Also, it was important that the patient received immediate surgery, before she deteriorated. Bile peritonitis is a life-threatening situation. The sooner it is corrected, the better chance for survival.
This 5-yr-old FS Chihuahua was presented for a lameness. A cause was not found, and therapy for a strain was prescribed. One month later, she was presented for massive bruising around the axilla (armpit in photo 1). A CBC revealed anemia and an increased number of white blood cells. The worst bruising seemed to be on the caudal aspect of the humerus, in the axilla (photo 2). The bruising extended down the whole length of the ventral abdomen. On ultrasound examination, there was a mass overlying the cranial aspect of the humerus (photo 3). There was a fluid pocket just under the skin, where the mass had ruptured into the tissue (photo 4). The ultrasound also revealed that there was an enlarged axillary lymph node, which had similar architecture as the aforementioned mass (photo 5).
It was considered most likely that this mass and the enlarged lymph node and secondary swelling and bruising was the result of a malignant tumor, in particular a hemangiosarcoma. The tumor appears to have metastasized to the lymph node. A biopsy would be needed to make a definitive diagnosis. The biopsy could be done with a short anesthetic procedure. Unfortunately, complete resection of the mass and lymph node was not an option. Thus, the long-term prognosis is poor for this dog. Supportive care can be given to make her as comfortable as possible, for as long as possible. Hospice-like care will be provided with pain relievers and anti-inflammatory medications.
One sad part of this case is how young this sweet dog is (5 years old). Unfortunately, aggressive tumors can affect young dogs as well as old dogs.
This 7-yr-old Mastiff dog had an approximately 3-month history of inappetence and intermittent diarrhea. Then, she became very lethargic and weak. On palpation, pain was elicited in the cranial abdominal region. In-house blood work on 10/7/17 showed increased liver and pancreas values, with leukocytosis and neutrophilia. Radiographs showed a diffuse loss of peritoneal serosal detail. An abdominal ultrasound was performed and revealed that the duodenum was thickened and corrugated, and there was a linear foreign body within the duodenum (photo 1-3). There was corrugation between the different segments of the foreign body. The foreign body was considered to be something like a sock or something that can stretch to form a linear shape. Surgery was recommended. Surgery was performed the next day (see photo 4).
The first thing they teach you in veterinary school is that cats are not dogs. Here is a case that exemplifies this.
This ultrasound image is from 12 yr old, female, spayed cat that was presented for a possible abdominal mass. The mass had been found on a routine exam, and was thought to be a splenic mass. Despite the findings on exam, she had no clinical signs. The ultrasound evaluation revealed an enlarged spleen (see photo), with a curl cranially. This would be considered a normal spleen if it was in a dog, but in a cat, the spleen was way too large. An aspirate was taken from the spleen, and sent to the laboratory for cytologic evaluation. The results revealed a splenic mast cell tumor.
This 3-year-old female spayed Wheaten terrier had symptoms and chest radiographs that were suggestive of Valley Fever. She had just moved to Arizona from California, a week prior to visiting the veterinarian here. She had only been to Arizona once before, on a visit in December, 2016. She was coughing and had a fever, and her blood work showed signs of inflammation. However, serologic testing for Valley Fever (Cocci serology) was negative. She was treated with an antibiotic, fluconazole (an antifungal drug), and an appetite stimulant, but she “did not improve”, according to the owner.
A cardiothoracic ultrasound by PVIMS was performed to try to make a definitive diagnosis. The heart was found to be normal, but enlargement of the hilar lymph nodes was discovered (ultrasound picture 1), along with a nodule in the right caudal lung lobe (2nd ultrasound picture), adjacent to the diaphragm. Using ultrasound guidance, fine needle aspirates of the lung nodule were obtained, and were submitted for cytology and cultures (aerobic, anaerobic, and fungal)(3rd ultrasound picture). The cytology came back as neutrophilic inflammation. The fungal culture grew the “Valley Fever organism”-Coccidioides immitis.
Using this information, we could definitively tell the owner that Valley Fever is her pet’s problem, and that we need to give the fluconazole enough time to work. The patient had only received 2 weeks of antifungal therapy, so far. Importantly, it often takes several months of antifungal therapy for patients to feel back to normal, and antifungal therapy has to be given for up to a year when treating Valley Fever. Also, it is important to note that the serologic test was negative in this case, so this test is not always diagnostic. A tissue sample is sometimes needed to make a definitive diagnosis.
Here’s something we don’t see every day. It’s a segment of the small intestines that has telescoped on itself. It is hard to explain-- and spell. It is called an intussusception. See Google images to understand it better. Then look at these ultrasound images that came from a 9yr, F/S, mixed breed dog who was initially presented to her first veterinarian in April, 2018, for vomiting, diarrhea, inappetence and extreme weight loss (Figure 1). On palpation, a suspect abdominal mass was noted. Radiographs confirmed the suspect mass. Blood chemistry revealed a low total protein (4.4 g/dL) and albumin (2.2 g/dl). She was treated with mirtazapine and metronidazole, but this only helped temporarily. She presented to her second veterinarian in mid-May for a recurrence of the clinical signs.
An abdominal ultrasound revealed a large intussusception (a telescoping of one small intestinal loop into another, Figure 2). On cross section, one small intestinal loop looks to be contained within the other (Figure 3). No mass could be found at the base of the intussusception (Figure 2).
Exploratory surgery was performed the next day. The intussusception (Figure 4) was reduced, and a small mass was found within the small intestine (Figure 5). This mass was surgically removed, and it was defined via histopathology to be an intestinal stromal tumor. Following the surgery, she healed rapidly and is reportedly doing very well.
There often is an underlying cause for an intussusception to occur. In young dogs, intestinal parasites are often to blame. In older dogs, intestinal tumors are the most common cause. The tumor is often benign. This patient will hopefully be cured of her problems, now that the corrective surgery has been done.
Here's an ultrasound picture (Figure 1) from Lulu, an 11-year old, female, reportedly spayed Chihuahua that was seen for lethargy. This lethargy was sudden in onset. In fact, the patient was seen 1 week prior for a wellness check, and her examination was normal. She had blood and urine tested 1 week prior to having the ultrasound done, and all was normal. On examination besides for being lethargic, she had a recently swollen vulva. When the owner adopted Lulu from the Humane Society many years before, she was told that Lulu had been spayed shortly before her adoption. At the same time an umbilical hernia was reportedly repaired.
An ultrasound was performed to look at her reproductive organs, since the swollen vulva suggests she had some hormone influence on her body. Sure enough, the ultrasound picture is of her fluid filled right uterine horn. The surgical picture (Figure 2) is of her uterus at surgery, fully distended with liquid. When it was opened up away from the patient, it was full of pus- consistent with a pyometra.
There are 2 lessons to learn from this case. First, one never knows what you will find with ultrasound until you look. Second, the history may not be right.
Now, this is yellow!
This 13 yr, FS, Bull Terrier was lethargic and anorexic. You may ask, why is she so yellow? The reason is that she has a marked increase in bilirubin that is causing her to be jaundiced (Figure 1). There are many reasons for jaundice to develop in dogs and cats. It often takes an abdominal ultrasound to define the cause. In her case, it was a large pancreatic mass (Figure 2) (likely a carcinoma) blocking her bile duct near its opening into the duodenum. Since the bile duct was blocked, it became dilated and tortuous (figure 3). Also, as a result, the gallbladder became distended (Figure 4) with an accumulation of material (sludge) within it, since the gallbladder could not empty normally.
The abdominal ultrasound was crucial in making this diagnosis. Otherwise, a more-expensive CT scan or more-invasive exploratory surgery would have had to be done to determine the cause.
This 1.5 yr old FS Pit Bull Terrier had a right-sided nasal discharge for at least 6 months. She was presented to 3 different veterinarians on 6 different occasions. She had been prescribed various antibiotics for a suspect bacterial rhinitis and was started on Fluconazole for suspect Valley Fever. None of these medications helped with the discharge. With frustrations, the owner finally presented her dog to a veterinarian who knew a rhinoscopy was needed. Guess what we found. You guessed it…. An intact almond. (Figure 1 & 2) It was removed, and post-removal both choanae were wide open (Figure 3). Figure 4 shows the dog with her almond. She has done wonderfully since the procedure.
Here’s how PVIMS can help. A 4-year old MN Cairn Terrier had a 3-month history of having blood on his stool. Sometimes there was diarrhea, sometimes not, but the blood was always in or on the stool. Multiple fecal tests were negative, and there was no response to medications. An abdominal ultrasound revealed an abnormal thickening of the colonic wall, just above and behind the prostate gland (image 1). It was suspected that this was either a polyp or another type of tumor. A colonoscopy was recommended to resect the suspect colonic mass. On colonoscopy, a fleshy colonic mass was found, 5 cm in from the anus (image 2-endoscopic view). The mass was able to be exteriorized using endoscopy (image 4). The mass was then surgically removed. After it was removed, it was clear to see that the mass extended at least 180 degrees around the colon (image 3). Histopathology revealed that this mass was a benign polyp. Because of its large size, there is a concern that the margins of excision were small. We will closely monitor to see if there is recurrence. If found to be re-growing, the mass will be easier to remove when it is small.
This 3 yr old MN Boxer had chronic anorexia for several months. A Valley Fever test was IgG positive with a relatively high titer of 1:64. He was started on Fluconazole but he had become emaciated and presented for trouble breathing. An echocardiogram revealed amild amount of pleural effusion with a moderate amount of pericardial effusion, causing compression of all chambers. As a result, the chambers were relatively small. This effusion contained many strands of tissue extending from the parietal pericardium to the epicardium, in a striated pattern (video). All surfaces of the heart were involved. The strands of tissue between the parietal pericardium and the epicardium represent areas of inflammation, most likely a result of the Valley Fever.
This cannot be treated with medical therapy alone. Instead, it would require removing the pericardium and trying to remove the inflammatory material from on the surface of the heart. Unfortunately, manipulation of the heart surface, and any peeling of this material off of the heart, typically causes irritation to the surface of the heart, and arrhythmias then develop. If the pericardium is left on, then constriction develops. The prognosis is very poor.
This 5 yr MN cavalier king Charles was previously presented for respiratory issues that would not resolve with antibiotics. An echocardiogram revealed marked increased echogenicity and thickening of the mitral valve leaflets, with prolapse of the both leaflets into the left atrium. Both of the leaflets which were almost touching the anterior wall (video). Based on the mitral valve thickening and the increased echogenicity of the mitral valve leaflets, bacterial endocarditis is suspected as the cause. He will be treated with a 6 week long course of antibiotics.