The diaphragm is the primary muscle of respiration, and its weakness can lead to respiratory failure. Diaphragmatic palsy can be caused by various causes. Injury to the phrenic nerve during thoracic surgeries is the most common cause for diaphragmatic palsy. Depending on the cause, the symptoms of diaphragmatic palsies vary from completely asymptomatic to disabling dyspnea requiring mechanical ventilation. On pulmonary function tests, there will be a decrease in the maximum respiratory muscle power. Spirometry shows reduced lung functions and a significant drop of lung function in supine position is typical of diaphragmatic palsy. Diaphragmatic movements with respiration can be directly visualized by fluoroscopic examination. Currently, this test is being replaced by bedside thoracic ultrasound examination, looking at the diaphragmic excursion with deep breathing or sniffing. This test is found to be equally efficient, and without risks of ionizing radiation of fluoroscope. Treatment of diaphragmatic palsy depends on the cause. Surgical approach of repair of diaphragm or nonsurgical approach of noninvasive ventilation has been tried with good success. Overall prognosis of diaphragmatic palsy is good, except when it is related to neuromuscular degeneration conditions.

Abiotrophia defectiva is nutritional deficient streptococci that cannot be cultured on routine culture medias. Even though fastidious in growth requirement, it is a virulent bacterium preferentially affecting endovascular structures and is implicated in many culture-negative endocarditis cases. Unlike other organisms, it is known for heart valve destruction leading to heart failure and excessive embolization rates. It's inherent resistance to routinely used antibiotics also contributed to increased mortality and morbidity in affected individuals and warrants timely diagnosis and prompt treatment. Our patient, a previous healthy individual, acquired this rare bacterium from intravenous drug abuse and developed infective endocarditis with valve destruction, heart failure, and distal embolization to multiple organs. He underwent multiple surgeries including mitral valve replacement and embolectomy with clinical improvement. Our case reiterates the possibility of rare cause of common diseases and raises awareness of infective endocarditis caused by A. defectiva among medical professionals.