A 23 year old male with a history of IVDU presented with pleuritic chest pain.  He denies fever but reports generalized malaise.  Bedside cardiac ultrasound shown below.  What's the diagnosis?  (scroll down for answer)

Answer:  Infective endocarditis with tricuspid valve vegetation

• Risk factors: IVDU, intravenous catheters, recent dental procedure, immunosuppression, prosthtetic valve or cardiac device
• Commonly S. aureus infection of the tricuspid valve in patients with history of IVDU, other bugs include streptococcus viridans,  streptococcus gallolyticus,  the HACEK organsisms (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella and Kingella)
• Majority will complain of fever, with associated night sweats, anorexia and weight loss
• Most will have a murmur on physical exam and roughly half will have one or more of the classical physical findings - petechiae, subungual splinter hemorrhages, macules on the palms and soles, retinal hemorrhages
• See the Modified Duke Criteria for diagnosis of infective endocarditis
• 4-6 weeks of intravenous antibiotics are required to treat infective endocarditis