Anamnesis
Male, 79 years old. Self-assisted. From Salto.
Pathological history: -Chronic arterial hypertension. Ex-smoker. -Diabetes mellitus type 2 with macro and microvascular repercussions (ischaemic heart disease, arteriopathy of MMII with amputation of both hallux, chronic kidney disease, diabetic retinopathy). -Aortic valve replacement surgery (AVR) for symptomatic severe aortic stenosis in March 2015 together with myocardial revascularisation surgery. Current illness: 8/11/16 Infection of the second toe of the right foot (fluxive signs and fever) which led to consultation in Salto, oral antibiotic therapy was indicated and complied with for seven days (the antibiotic is unknown) with transient remission of symptoms.

15/11/16 Confusional syndrome, fever 40o C axillary and dyspnoea. Reconsultation at the hospital in Salto.

On examination: GCS 12, FR 26 rpm, BP 100/60mmHg, Ta x 38.5o. Normal colour. Splinter haemorrhages and Osler nodules in hands. PP: bibasal crepitant rales. CV: RR 110 cpm, holosystolic ejective murmur 2/6 in mesocardium, IY and RHY discrete. Abdomen: soft and painless, no visceromegaly. PNM consciousness described, normal meningeal sector, no alterations of cranial nerves or spinal level. MMII amputation of both hallux, second toe of right foot with wet necrosis.

Relevant diagnostic tests
- RxTx Redistribution of flow to both vertexes. Congestive hilae.
- Haemoglobin 10 g/dL, WBC 10000/mL, platelets 49000/mL. ESR 74 mm/h.
- Creatinemia 3 mg/dL, azoemia 153 mg/dL.
- Blood gases: metabolic acidosis, normal ionogram.
- ECG: first-degree atrioventricular block (AVB)
- Blood cultures (2): Staphylococcusaureusmethicillin-sensitive Staphylococcus (SAMS) developed
- Transesophageal echocardiogram (TEE) 18/11: normofunctioning aortic biological prosthesis, aortic valve area 1.7 cm2 without leaks. Rounded 7x7 mm mass adhering to the free edge of the left leaflet and projecting into the aorta in systole. Mitral valve with calcification of the annulus and moderate mitral insufficiency.


Assessment of complications:
CT abdomen: images compatible with splenic infarction
ECG: second degree AVB
Aggravation of renal insufficiency with dialysis requirement

Diagnosis I
Infective endocarditis (IE) on prosthetic aortic valve, late.
Aetiology: sensitive Staphylococcus aureus methicillinus (SAMS). Complicated with heart failure, valve abscess, splenic infarcts and renal injury.

Treatment:
Cefazolin2g c/8 hs iv; gentamicin 3mg/kg/day iv; rifampicin 600 mg c/12 hsvo. Early surgical treatment is considered.

Evolution
72 hours after starting treatment (20/11): febrile/increased pulmonary oedema.
- Amputation of second toe.
- Evolves to complete AVB requiring transient pacemaker.
- TEE persists in very mobile mass of 7x7 mm attached to the left valvula. Mitroaortic thickening compatible with abscess. Mitral valve with calcified ring, small masses on the anterior leaflet on the atrial side, mobile.

Diagnosis II:
IE to late prosthetic aortic SAMS and complicated native mitral.
- Cardiac surgery on 23/11. PreQ prophylaxis: amikacin 1g and vancomycin 1g.
- Aortic valve replacement and mitral valve vegectomy
- Culture of aortic prosthetic material: no development.

In apyrexia, no evidence of heart failure. Confusional syndrome remitted. Pacemaker was removed, no reinstalled bradyarrhythmias in the evolution. Improvement of renal function figures. Creatinemia stable at 2 mg/dl. Completed 6 weeks of antibiotic treatment after surgery with cefazolin and rifampicin, having completed two weeks of IV gentamicin. Discharged on 9/12.
