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A 47-year-old woman with a history of paroxysmal atrial fibrillation presented with seizure. She noted progressive fatigue in the preceding 6 months. The week before admission, she had worsening headaches and increased irritability. On the day of admission, she developed an episode of grand-mal seizure. MRI of the brain revealed a round lesion in the left frontal lobe measuring 11 cm by 15 mm with an extensive halo of T2 hyperintensity surrounding the lesion and minimal inherent T1 high signal along the border. The lesion was suspicious for an abscess. She was taken to the operating room for biopsy. Craniotomy and corticectomy revealed an abscess cavity with a large amount of purulent material. Culture of the purulent drainage grew Streptococcus intermedius. She was started on penicillin G and metronidazole.A transthoracic echocardiogram revealed normal right and left ventricular size and function (Movie I in the online-only Data Supplement). There was mild left atrial enlargement without evidence for significant valvular abnormalities. Doppler interrogation of the septum in the subcostal view revealed abnormal color flow in the inferoposterior part of the interatrial septum suspicious for a left-to-right shunt ( Figure 1 and Movie II in the online-only Data Supplement). Chest x-ray to confirm placement of a peripherally inserted central catheter line showed the tip of the line overlying a left-sided superior vena cava (Figure 2).To further characterize her anatomy, a cardiac MRI was obtained. MRI with gadolinium contrast revealed a persistent left superior vena cava (PLSVC) opening into the left atrium (Figure 3). MRI also showed complete unroofing of the coronary sinus (Figure 4), which directly communicated with the left atrium and formed a left-to-right shunt. The coronary sinus was enlarged and measured 13 mm at its opening to the right atrium. The Qp/Qs shunt ratio was 1.8 to 1, indicating significant left-to-right shunting ( Figure 5A and 5B).The patient's left-sided peripherally inserted central catheter line was removed, and a new right-sided peripherally inserted central catheter line was placed for long-term antibiotic administration. After discharge, anaerobic cultures grew Capnocytophaga and treatment was changed to ertapenem. She completed an 8-week course of antibiotics. Repeat MRI of the brain

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