An ECG that changed in a febrile patient

A 50 year old man with a history of injecting drug misuse was admitted as an emergency with a reduced level of consciousness and left arm weakness after five days of swinging fever, rigors, and headache. His medical history included hepatitis C infection, paroxysmal atrial fibrillation, and a recent hospital admission with discitis and psoas abscess. His temperature was 38.4°C, but he was haemodynamically stable and alert. He had a soft early diastolic decrescendo murmur along the left sternal border. Splinter haemorrhages were present, along with a small digital infarct of the left third toe and mild upper motor neurone pattern weakness in the left arm. Laboratory investigations confirmed a normocytic anaemia and leucocytosis and blood cultures grew meticillin resistant Staphylococcus aureus. Computed tomography of the brain showed a hypodense area in the left frontoparietal area consistent with infarction