A 40-year-old man who was a smoker with no history of intravenous drug use presented to a tertiary hospital with a week-long high-grade fever, dry cough, and streaky hemoptysis. He had hypoxia at room air. Chest x-ray showed bilateral ground-glass opacities with relative sparing of apexes and left base (Figure 1).Sputum and blood cultures (including fungal) and HIV tests were negative. He had received intravenous piperacillin and tazobactam empirically for a week, with fair clinical improvement and resolution of radiological shadows. He was referred to our tertiary center for further management. Ocular fundi had multiple preretinal hemorrhages, a few with central clearing (Figure 2).Transthoracic echocardiogram revealed a bilobed, oscillating, 2ϫ1.5-cm right ventricular mass with peduncle arising from the anterior end of the moderator band ( Figure 3A and Movie I of the online Data Supplement).Transesophageal echocardiogram ( Figure 3B and Movie II) showed a 2-mm patent foramen ovule, and all valves were normal. The mass was visualized in a modified 4-chamber midesophageal view. Sixty-four-slice computed tomography pulmonary angiography showed no filling defects in the pulmonary artery. Cardiac magnetic resonance imaging (Figure 4 and Movie III) showed the contrast-nonenhancing mass and confirmed a structurally normal heart. His blood cultures were negative even after prolonged culture. He was started on empirical endocarditic therapy with vancomycin and gentamicin on suspicion of the mass being infective vegetation. Because the fever continued beyond a week of antibiotics, the decision to remove the mass was made.He underwent right atriotomy under cardiopulmonary bypass. The right ventricle and tricuspid valve were normal. A linear 2ϫ0.5-cm pale white growth and a smaller 0.5ϫ0.5-cm pale gray growth that were loosely attached to the moderator band were noted and removed. Right ventricular endothelium was normal throughout, and excision of the moderator band was not done.Histopathological examination showed fibrinous material with predominantly neutrophilic infiltrates ( Figure 5) and Gram-positive cocci (Figure 6). Culture of specimen yielded Staphylococcus aureus sensitive to methicillin and gentamicin. Hence, oxacillin and gentamicin were continued for another 2 weeks. The patient became afebrile, and C-reactive protein values were normalized. He was doing well at the 1-year follow-up visit.

SUMMARY'The Big four' are the most poisonous snakes in India, and especially in Kerala. These include the cobra, the viper, the krait and the sea snake. Most of the poisonous snakebites in India occur in Kerala. We believe there are only a few reports of myocardial infarction after snakebites and most of these are viper bites. We believe this is the second case of primary angioplasty for a snakebite. There are at least a few potential issues in performing a primary angioplasty in a snakebite case, namely (1) Is it a thrombus or a spasm? (2) Are the bleeding parameters deranged? Will the patient tolerate tirofiban and other glycoprotein (GB) 2b3a inhibitors? Will he develop dangerous bleeding due to the high dose of heparin needed? Further, would we save the patient from myocardial infarction only to lose him to renal failure, both due to the nephrotoxicity of the venom, the kidney being further damaged by the contrast media used for the angioplasty? We discuss all these issues as they crossed our mind, and hope it will help further treatment in others. We would like to review the available literature on these points and describe a recent case of ours. BACKGROUND

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