A 12-year-old girl was admitted for the evaluation of fever and mental status change. She was diagnosed with subaortic stenosis in the first year of life, and treated with surgery at 4 years of age. At age 7 she developed severe aortic stenosis and received an aortic valve replacement. She remained healthy after this procedure until presenting to the hospital complaining of the sudden onset of fever, nausea, vomiting, and headache. She also complained of joint pain localizing to her large joints. She had no rashes or skin manifestations of endocarditis, no recent dental procedures or other surgeries, and no seizures. She had no observable joint swelling or redness. She had a systolic murmur. She was sleepy but arousable, was oriented to year and place but not month or date, and could follow simple but not two-step commands. She had a right homonymous hemianopia. Motor, sensory, and coordination testing was normal. She had bilateral Babin-ski responses and symmetric hyperreflexia without spasticity or clonus.
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