Six Days After Being Admitted to the Hospital for Cholecystectomy

Six days after being admitted to the hospital for cholecystectomy, a 56-year-old woman has high-grade fevers, chills, malaise, and generalized weakness. She has been hospitalized twice in the last year for acute cholecystitis. She had a molar extraction around 2 weeks ago. She has mitral valve prolapse, hypertension, rheumatoid arthritis, and hypothyroidism. Current medications include metformin, rituximab, levothyroxine, and enalapril. Her temperature is 38.3°C (101°F) , pulse is 112/min, and blood pressure is 138/90 mm Hg. Examination shows painless macules over her palms and soles and linear hemorrhages under her nail beds. The lungs are clear to auscultation. There is a grade 3/6 systolic murmur heard best at the apex. Blood is drawn and she is started on intravenous antibiotic therapy. Two sets of blood cultures grow Streptococcus gallolyticus (formerly S bovis) . Echocardiography shows a large oscillating vegetation on the mitral valve and moderate mitral regurgitation. Additional workup for this patient should focus on which of the following conditions?

A) Colonic neoplasia
B) Intravenous drug use
C) Lung cancer
D) Oral infection
E) Urinary tract infection