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A 58-year-old woman with end-stage renal disease presented with fever and rigors after undergoing hemodialysis. There was a 2/6 diastolic decrescendo murmur along the left sternal border. An echocardiogram showed a large, mobile mass on the aortic valve and moderate-to-severe aortic regurgitation. Two sets of blood cultures grew Pseudomonas aeruginosa. During the patient's hospital stay, an unusual physical finding developed (see the video, available with the full text of this article at www.nejm.org). Müller's sign is the pulsation, or bobbing, of the uvula during systole, infrequently seen with severe or sudden-onset aortic regurgitation. In this patient, the pulsation extended to the soft palate and posterior oropharynx. Like many of the other physical findings associated with aortic-valve insufficiency, such as Musset's sign and Quincke's pulse, Müller's sign is a result of markedly increased stroke volume. The patient declined surgical intervention and was treated with intravenous antibiotic therapy. She died two weeks later.
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