LAUSR

To the Editor: A 53-year-old woman with a history of diabetes type II presented to the emergency department with diarrhea. She was treated with intravenous (IV) fluids and antibiotic (ceftriaxone and metronidazole) for suspicion of colitis. However, her abdominal pain did not resolve, so a computed tomography of the abdomen was performed. It showed stenosis involving the proximal superior mesenteric artery. Given the finding of arterial stenosis on computed tomography and a newonset worsening left-leg pain and tingling, an angiogram was performed. It showed widespread stenosis including superior mesenteric artery which was managed by angioplasty (Figure 1), right external iliac artery and left superficial femoral artery, and complete occlusion of the left popliteal artery due to embolus requiring thrombectomy. Systematic therapy including aspirin 81 mg daily and heparin infusion (18 units/kg/h) were administered. The patient underwent further workup to explore the source of her symptoms and widespread thrombosis. Transthoracic echocardiogram and transesophageal echocardiogram demonstrated low ejection fraction of 45% with wall motion abnormalities, aortic valve vegetation measuring 0.73 0.3 cm (Figure 2), and atrial septal defect (ASD). Blood cultures were negative. However, infective endocarditis of the aortic valve was believed to be the cause of the embolic phenomenon and the patient received 6 weeks of vancomycin and cefepime. Shortly after, she complained of right-leg pain and an ultrasound of lower extremities revealed deep vein thrombosis (DVT) of the right femoral vein. She was started on enoxaparin (1 mg/kg twice daily) and bridged to warfarin. The patient had widespread extensive ischemia and thrombosis along with abnormal transesophageal echocardiogram with low ejection fraction. The