PERSONAL HISTORY
No known drug allergies. Cardiological history: ventricular septal defect under follow-up by cardiology. No known cardiovascular risk factors (CVRF). No surgical interventions. No contact with animals. No toxic habits. No habitual treatment.

CURRENT ILLNESS
Patient with a history of febrile fever and thermometric fever of up to 38 ̊C with profuse night sweats for the last two years. She did not report any other accompanying infectious symptoms. She also has a general syndrome with a weight loss of 10 kg in the last year (4 kg in the last month). For the last week she has been complaining of moderate exertion dyspnoea with orthopnoea.  

PHYSICAL EXAMINATION
Good general condition. Blood pressure 130/60 mmHg. No peripheral adenopathies or skin lesions. Cardiac auscultation: rhythmic at 100 bpm, systolic murmur in FM II/VI, aortic systolic murmur III/VI with diastolic leakage IV/IV. Pulmonary auscultation: bibasal crackles. Abdomen soft, depressible, without masses or megaliths, preserved hydro-aerial sounds. Not painful on palpation. Lower extremities without oedema.


COMPLEMENTARY TESTS
CBC: leukocytes 11,800 (90% polymorphonuclear), Hb 13 g/dl, platelets 195,000. VSG 23. PCR 11. LDH 334. Glomerular filtration rate 95 ml/min. Proteinogram compatible with inflammatory process. Autoimmunity negative. Beta2 microglobulin 3.62, NT-proBNP 2.360 pg/ml. Bronchoaspirate: negative microbiology. Mantoux negative. Other laboratory tests were normal. ECG: sinus rhythm at 95 bpm, normal PR, wide QRS with morphology of complete left bundle branch block (LBBB), left ventricular (LV) enlargement, left axis deviation.
Blood culture + antibiogram: Abiotrophia defectiva sensitive to cephalosporins. Chest X-ray: increased cardiothoracic index, signs of vascular redistribution and presence of fluid in cystole.
Echocardiogram: left ventricular dilatation (LVEDD 64 mm) with preserved EF, without segmental contractility abnormalities. Images suggestive of infective endocarditis on the aortic valve, with valvular rupture causing grade IV insufficiency, functional mitral regurgitation grade III (Carpentier's type I, due to dilatation of the annulus), with left atrial dilatation and severe pulmonary hypertension at rest. Tricuspid valve involvement (septal leaflet) with severe regurgitation. Restrictive infracristal infracristal perimembranous ventricular septal defect (gradient 66 mmHg).
Other complementary tests:
Gastroscopy: normal. Duodenal biopsies without alterations. Colonoscopy: haemorrhoids. No other findings.
Thoracic-abdominal CT scan: no lesions. Coronary CT: calcium score 0. Coronary arteries without plaques or lesions.
Culture of aortic and tricuspid valve vegetation: positive for Abiotropha defectiva.

CLINICAL EVOLUTION
The patient was admitted to the hospital with a general syndrome, fever and dyspnoea. After positive blood cultures for Abiotrophia defectiva (former Streptococcus viridans), antibiotic treatment was started with ceftriaxone. Diuretic treatment was also associated with diuretic treatment to control congestive symptoms. An echocardiogram was performed, showing infective endocarditis on the tricuspid and aortic valves, with severe aortic insufficiency and dilated LV. After adding gentamicin to ceftriaxone, he remained afebrile. A gastroscopy and colonoscopy were performed, with no evidence of active bleeding, and a CT scan of the abdomen and pelvis showed no evidence of masses or other relevant pathology. He was presented at the medical-surgical session and was accepted for surgical treatment. He underwent surgery: placement of a mechanical aortic prosthesis, mitral annuloplasty and tricuspid annuloplasty and closure of the ventricular septal defect (VSD), without complications. After a joint assessment with the infectious diseases department, antibiotic treatment was decided 6 weeks after surgery, and he was transferred to cardiology to complete treatment. Antibiotic treatment was completed and a control echocardiogram was performed with no images suggestive of vegetations, and the patient was discharged from hospital.

DIAGNOSIS
Endocarditis on aortic and tricuspid valve. Heart failure with preserved ejection fraction, secondary to valvular heart disease. Grade IV aortic insufficiency due to valve destruction. Grade III tricuspid regurgitation due to destruction of the septal leaflet. Grade III functional mitral insufficiency. Perimembranous ventricular septal defect. Severe pulmonary hypertension at rest. Aortic valve replacement by mechanical prosthesis, mitral annuloplasty, tricuspid annuloplasty and VSD closure.
