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Lack of efficacy, haemorrhagic stroke and drug rash: case report A 53-year-old woman developed haemorrhagic stroke during treatment with heparin and aspirin for acute coronary syndrome (ACS). Additionally, she developed drug rash during treatment with nafcillin for infective endocarditis, and exhibited lack of efficacy while being treated with nitroglycerine for ACS [not all dosages and routes stated]. The woman, who had a history of hypertension, presented to the hospital with complaints of chest pain, which worsened with inspiration and supine positioning and relieved by sitting forward. She also complained of poor oral intake, malaise and diffuse myalgias. Based on investigations, she was diagnosed with ACS. ST segment myocardial infarction due to occlusion of the right coronary artery ostium was also noted. She was started on sublingual nitroglycerin; however, she did not get relief. Hence, she was initiated on morphine along with 325mg of aspirin. She also started IV heparin bolus and infusion. She was transferred to other facility for further evaluation and management. Based on further investigations, she was considered to have presumed myopericarditis. The woman’s heparin therapy was discontinued. She was initiated on naproxen and colchicine. On day 2 of hospitalisation, she experienced substernal chest pain, altered mental status and new ST elevation was also noted. She was later diagnosed with rightsided homonymous hemianopsia. Her CT and the MRI of the brain revealed left-sided parietal-occipital haemorrhagic infarct and a right frontal cortical stroke, indicating haemorrhagic stroke. She was transferred to the ICU. Her blood cultures were found to be positive for methicillin-susceptible staphylococcus aureus. She was diagnosed with infective endocarditis and was started with IV nafcillin. Cardiothoracic surgery was proposed. An invasive angiography was contraindicated due to her aortic valve endocarditis and haemorrhagic stroke. Eight days after transfer to the ICU, she was hemodynamically stable and free of chest pain. There was no recurrence of ST elevations. Moreover, on day 10 of hospitalisation, she experienced ventricular fibrillation arrest, which required CPR and defibrillation. It was decided to proceed aortic valve surgery after achieving return of spontaneous circulation. She underwent a high-risk aortic valve debridement. She experienced ventricular tachycardia on post-operative day 2, which required urgent coronary angiography and percutaneous coronary intervention with a drug-eluting stent to a 90% stenosis of the ramus intermedius artery. For further recovery, she was transferred to an inpatient rehabilitation. Two weeks after the surgery, she was readmitted for brain abscess, which was managed conservatively with unspecified IV antibiotics. She was readmitted 4 weeks after the surgery for subsegmental pulmonary emboli managed conservatively without anticoagulation due to her recent haemorrhagic stroke. She also developed a drug rash to nafcillin; hence, her antibiotic was changed to