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A 76-year-old heavy smoker with vascular disease, mitral valve repair and creatinine 1.4 mg/dL was admitted with fever. Blood cultures grew Enterococcus faecalis and echocardiography demonstrated mitral and aortic valve vegetations. Ceftriaxone (2 g twice daily) and ampicillin (3 g three times a day) were started with defervescence, but creatinine slowly rose to 3.3 mg/dL. On treatment day 14, he became agitated, confused, then comatose (Glasgow Score 4/15) without localising neurological signs. No abnormality to explain the coma could be found. Cerebrospinal fluid (CSF) was normal. Haemodialysis had no effect. Neuroimaging was unremarkable. Electroencephalography (EEG) demonstrated triphasic waves (TWs) (figure 1 …
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