A 36-year-old woman receiving long-term steroid therapy for lupus nephritis was admitted to Northwestern Memorial Hospital, Chicago, for the evaluation of a persistent fever. Three months before admission to the hospital, the patient developed progressive renal failure requiring hemodialysis. Her hospital course was complicated by the development of a catheter-induced enterococcal bacteremia, requiring parenteral broad-spectrum antibiotics. An arteriovenous fistula was created for long-term hemodialysis. One week before admission to the hospital, she again developed a fever and had a temperature of 38.8°C with diarrhea and headaches. Blood samples for cultures were drawn during dialysis. At the time of hospital admission, her vital signs were as follows: blood pressure, 90/50 mm Hg; pulse rate, 97 beats per minute; and temperature, 37.5°C. Splinter hemorrhages were present on her fingers. On cardiac examination, the S, was diminished and the S2 was normal. A grade 3/6 holosystolic murmur was heard best at the
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