Pupil dilation at the first well baby examination for documenting choroidal light reflex

were negative. The patient was referred by her pediatrician for possible endocarditis. Ten days before the onset of fever, her orthodontist had adjusted her braces. Physical examination revealed her to be thin, pale, well-developed, and in no distress. Heart rate was 128 beats/min; respiratory rate, 12 breaths/min; blood pressure, 82/60 mm Hg; and temperature 38.4 ~ C. The patient had halitosis. Funduscopic examination showed no hemorrhages. There were no carotid bruits, and the lungs were clear. The precordium was quiet; there were no lifts or thrills. The heart sounds were normal; there were no gallops, rubs, or clicks. A grade II1/VI pansystolic murmur was heard maximally at the mid-left sternal border, with some radiation along the sternal border. Peripheral pulses were normal and equal in all extremities. No hepatosplenomegaly was present. The skin had no rashes or petechiae. Significant admission laboratory data included a hemoglobin level of 11.3 gm/dl and a leukocyte count of 9200 mm 3, with 67% segmented cells, 17% band cells, 12% lymphocytes, 3% monocytes, and 1 atypical cell. The platelet count was normal, sedimentation rate was 85 mm/hr, and antistreptolysin O titers were normal. A chest roentgenogram and an electrocardiogram were normal. An echocardiogram showed a small vegetation on the septal leaflet of the tricuspid valve. Three blood cultures were positive for Streptococcus viridans. The patient was treated intravenously for 5 weeks with penicillin (3 weeks in the hospital and 2 weeks at home) and for 17 days with gentamicin. The vegetation disappeared, and she remains well 7 months after the onset of fever.