A 52-year-old man with history of intravenous drug abuse and immunosuppression due to HIV-infection was admitted for community-acquired pneumonia after presenting with dyspnea, productive cough, leukocytosis, and lobar infiltration on chest x-ray. Blood cultures obtained on admission before antibiotic administration were negative. A new heart murmur was detected, warranting further evaluation with transthoracic echocardiography (TTE), which revealed a large 2.3 × 2.5 cm echo-free space adjacent to the left atrium (LA) (Movie 1) with turbulent systolic flow into the LA (Movie 2). Trans-esophageal echocardiography demonstrated a cystic opening immediately above the mitral valve (MV) perforating through the posterolateral wall of the LA with marked systolic inflow from an adjacent echo-free space, most likely representing a pseudoaneurysm (Movies 3, 4, and 5). The MV leaflets appeared intact without attached vegetation, and a bubble study was negative.
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