PERSONAL HISTORY
79-year-old woman, allergic to penicillin and metamizole. She is a Jehovah's Witness and therefore formally refuses blood transfusions. Cardiological history: arterial hypertension, chronic atrial fibrillation, and carrier of Omnicarbon No 29 mitral valve prosthesis (implanted 30 years ago) due to severe rheumatic mitral valve stenosis. Annual follow-up in cardiology outpatient clinic. Home medication: acenocoumarol, furosemide 20 mg/24 hours, losartan 50 mg/12 hours, omeprazole 20 mg/24 hours, digoxin 0.25 mg/24 hours (5 days a week).


CURRENT ILLNESS
The patient presented in the last 9 months with progressive clinical symptoms of asthenia and dyspnoea on moderate exertion, with jaundice of the skin and mucous membranes. She was admitted to the gastrointestinal department for anaemia, ruling out biliary or pancreatic involvement or any other digestive pathology that might justify it.
 Due to the haemolytic profile of the anaemia (elevated bilirubin at the expense of the indirect fraction, elevated reticulocytes, undetectable haptoglobin, etc.) in a patient with a prosthetic valve, she was transferred to the cardiology department to rule out possible prosthetic valve dysfunction.
 
PHYSICAL EXAMINATION
Conscious, oriented and well hydrated. Cutaneous-mucosal jaundice. Marked increase in jugular venous pressure (estimated CVP of 16 cmH2O).
Cardiac auscultation: arrhythmic heart sounds at 84 bpm with systolic murmur II/VI in mitral focus. Pulmonary auscultation: preserved vesicular murmur. Abdomen: no alterations. Oedema with fovea up to the middle third of the lower extremities, in addition to signs of chronic venous insufficiency.

COMPLEMENTARY TESTS
Biochemistry: creatinine 1.25 mg/dl, normal ions and transaminases, basal glucose 91 mg/dl, total cholesterol 145 mg/dl, LDH 1,308 U/l, haptoglobin absent, increased reticulocytes (7%), increased total bilirubin 2.1 mg/dl and direct bilirubin 0.6 mg/dl. Direct and indirect Coombs test negative. Vitamin B12 and folic acid normal. Mild iron deficiency (IST 15%). Haemoglobin 8 g/dl, haematocrit 24%, platelets 71,000/mm3.
Transesophageal echocardiography: normofunctioning mitral prosthesis with moderate periprosthetic leak (in the posterior wall; at 5-6 hours) of 9 x 5 mm with regurgitation not reaching the atrial roof. Free atrial appendage. Normal sized left ventricle (LV) with mild concentric hypertrophy and preserved systolic function (EF 67%). Dilatation and mild dysfunction of the right ventricle (RV). PET-CT scan No 1: increased fixation of the periprosthetic radiotracer (in the form of an incomplete ring) suggestive of endocarditis on mitral prosthesis. PET-CT scan No 2: resolution of periprosthetic uptake is observed.

CLINICAL EVOLUTION
Given a severe haemolytic anaemia in a patient with a metallic valve prosthesis without any other cause, a transesophageal echocardiogram was requested which confirmed a de novo perivalvular leak with associated moderate mitral insufficiency. Due to the appearance of a new paravalvular leak, a PET-CT scan was performed in search of an aetiology, showing perivalvular uptake suggestive of infective endocarditis. Although the patient was afebrile throughout admission and all blood cultures were negative without having received previous antibiotic treatment, he had high titres of Coxiella IgG, so antibiotic treatment was started with ceftriaxone for 6 weeks and doxycycline for 18 months. Six weeks after starting the antibiotic regimen, a new PET-CT scan was performed, which no longer showed mitral uptake. Treatment with erythropoietin and folic acid was also started to treat the haemolytic anaemia. Despite the resolution of the infectious condition, asthenia and anaemia persisted in the context of valve dysfunction, so it was decided to intervene on the valve. Due to the high surgical risk of open surgery, increased by the patient's refusal to use blood transfusions and blood products, it was finally decided to proceed with percutaneous closure of the paravalvular leak. Postoperative transesophageal echocardiography (TEE) was performed and showed an acceptable result.

DIAGNOSIS
Late infective endocarditis on mitral prosthesis due to Coxiella burnetii.
Haemolytic anaemia due to prosthetic dysfunction. Percutaneous closure of periprosthetic leak.
