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Although patients with certain cardiac valve abnormalities have increased risk of infective endocarditis (IE), it is unknown whether these abnormalities are associated with specific pathogens in IE cases. We report a strong association between mitral valve prolapse and viridans group streptococcal IE in a population-based cohort from Olmsted County, Minnesota.

The VisualDx system (http://www.logicalimages.com/prodVDx.htm) is a JAVA-based decision-support program developed by Logical Images to be used in clinical care to develop differential diagnoses based upon morphologic finding- and patient finding-driven searching. It consists of several modules, many of which are very relevant to infectious diseases specialists, such as Fever & Rash; International Travel; Drug Eruptions; Smallpox Vaccination; Terrorism Recognition; Immunocompromised, HIV or AIDS; Female Genital Rashes & Growths; and Male Genital Rashes & Growths. Unlike books and atlases indexed by disease, with VisualDx, clinicians can enter patient descriptors and lesion morphologies, resulting in rapid assistance with differential diagnosis. VisualDx also increases clinician awareness of, knowledge about, and skills in the recognition of chemical warfare, bioterrorism, and radiation injuries.

Blastomycosis can occasionally involve the central nervous system (CNS). Amphotericin B deoxycholate is considered the drug of choice for the treatment of CNS blastomycosis. Significant toxicity may be associated with its use. We describe a case of cerebral blastomycoma that was successfully treated with voriconazole.

TO THE EDITOR—We commend Barsic and investigators from the International Collaboration on Endocarditis for their important contribution [1]. Their work represents the first study that evaluates the timing of surgery after stroke in infective endocarditis (IE) with risk adjustment for differences in patient characteristics [2]. The authors concluded that the timing of surgery has no impact on inhospital survival, although the adjusted odds ratio (OR) for mortality with early surgery (within 7 days of stroke) was 2.308 (95% confidence interval, .942– 5.652; P = .065). In fact, there was a trend to a statistically significant increase in mortality. This OR could potentially, if the sample size was slightly larger, imply that early surgery is associated with higher mortality. We suggest that the authors perform additional analyses to further explore this important issue. One approach involves using propensity score analysis in the surgical cohort of IE patients with stroke similar to the methods used by our group [3] and Thuny et al [4]. Another approach would be to examine the impact of early surgery in the total cohort (medical and surgical) of IE patients with stroke similar to the method used by Kim et al [5] and after adjusting for survivor bias [6]. An OR of 2.3 raises concerns about early surgery in IE patients with stroke and should be further evaluated before early surgery is considered safe in this patient population.