Infectious endocarditis (IE) has a high mortality and morbidity rate despite advances in antibiotic and surgical treatments. The tricuspid valve is involved in the majority of the right-sided infective endocarditis (RSIE), with Intravenous drug users (IDUs) been the highest group at risk. IE has different clinical manifestation depending on the affected cardiac valve. While left-sided IE (LSIE) presents with systemic embolization in 22% to 50 % of cases, RSIE mainly manifests with fever, bacteremia and septic pulmonary emboli. This report presents a tricuspid valve IE with right and left-sided IE clinical manifestations. This unusual case due to Staphylococcus aureus infection complicated with pulmonary septic emboli and a paradoxical embolism that damaged the pituitary gland. A 29 years old man, intravenous drugabuser, initially presented to the emergency room of a referring center with respiratory failure due to acute intoxication with cocaine. Once intubated, he had a cardiac arrest managed by cardiopulmonary resuscitation (CPR) for 3 minutes until a regular heart rate was obtained. A pulmonary X-ray was performed and revealed a bilateral pulmonary infiltrates with a massif pleural effusion. Pulmonary drains were placed. Blood tests showed a leucocytosis and a positive hemoculture with methicillin-resistant Staphylococcus aureus (MRSA). Intravenous treatment with Vancomycin (Pfizer, 15 mg/kg) and Daptomycin (Cubicin®, Novartis, 6 mg/kg) was started. Urine output was around 1230 ml/8h. Laboratory analyses revealed a low 6 AM cortisol level at 180 nmol/L, hypernatremia with blood sodium level at 150 mmol/L, serum osmolarity at 313 mmol/kg and urine sodium value less than 20 mEq/L. The thyroid-stimulating hormone (TSH) was at 0,03 mU/L with a serum total thyroxine (T4) at 7,5 nmol/L (Table 1). Trans-esophageal ultrasound showed massif vegetation of 36 x 28 mm on the septal leaflet of the tricuspid valve and a tricuspid insufficiency 3/4 intra/peri vegetation, probably due to a destruction of the septal leaflet. Cardiac ejection fraction was normal, and other cardiac valves were preserved. With the above clinical presentation and imaging finding, the diagnosis of tricuspid valve infectious endocarditis was made. The patient was then transferred to our institution for surgical management. He was in critical anasarca with edema in the lower limbs and crackles on the pulmonary examination. An abdominal tomodensitometry showed no lesions on the adrenal glands and no cerebral lesions on the cerebral tomodensitometry. Operation and post-operative course: The patient was brought to the operating room. After induction of general anesthesia, an incision is made 1 cm under the angle of Louis to the xiphoid process. The patient's altered level of consciousness and his pulmonary infection makes him at risk of an acute respiratory failure at the time of weaning of the mechanical ventilation. For that reason, an inferior ministernotomy is made to spare the manubrium in case a tracheostomy is needed. The sternal opening is made until the 3rd intercostal space, and the extracorporeal circulation was started with cardioplegia to stop cardiac activity during the surgery. The right atrium was then opened to see the tricuspid valve. The vegetation, measuring more than 3 cm, was visible on the septal leaflet of the tricuspid valve. This lesion was resected entirely and sent to microbiology for analysis. Another vegetation on the anterior leaflet was also resected. A complex tricuspid valve reparation was made using autologous pericardium. An anteroseptal commisuroplasty were also performed. During the surgery, a patent foramen oval was noticed and closed with an overcast suture using Prolene 4-0. Coming off cardiopulmonary bypass, the trans-oesophageal ultrasound showed a small leak on the tricuspid valve without any residual vegetations. At the end of the surgery, the patient is then transferred to the intensive care unit with stable vital signs and sinus heart rate.