Endocarditis Quiz: Ace Your Exams

A 45-year-old man with a history of systemic lupus erythematosus, end-stage kidney disease on dialysis, diabetes, and hypertension presents to the emergency department with a two day history of fever, chills, and dyspnea on exertion. The patient reports he receives dialysis 3 times/week and has not missed any of his scheduled appointments. He last received dialysis two days ago. Temperature is 38.7°C (101.6°F), pulse is 104/min, respirations are 24/min, blood pressure is 90/62 mmHg, and oxygen saturation is 90% on room air. On physical examination the patient is ill-appearing. There are erythematous lesions noted on the chest and arms bilaterally, as well as a fistula with a palpable thrill in the left arm without evidence of overlying erythema, discharge, or excoriation. A holosystolic murmur is appreciated at the lower left sternal border. Which of the following best describes the pathogenesis of this patient’s disease process?