A 77-year-old male patient with a clinical history of arterial hypertension, permanent atrial fibrillation with anticoagulation, and a surgical history of implantation of a definitive endocavitary VVI pacemaker several years ago.

The patient suddenly presented with language impairment, characterised by difficulty in uttering and understanding language, and behavioural changes, for which he was taken to the emergency department.

Physical examination revealed a fever of 38.1 °C. Pulmonary auscultation showed slight crackles, predominantly in the left base, with no signs of bronchospasm. Cardiac auscultation revealed protodiastolic acoustic vibration in the pulmonary focus. The neurological examination showed the patient to be conscious, not speaking and obeying simple commands.

A CT scan of the brain showed left frontal intraparenchymal haemorrhage and doubtful left fronto-parietal hypodensity. Chest X-ray showed left pleural effusion. Blood cultures showed S. bovis type I (gallolyticus).

To rule out possible endocarditis, an echocardiogram was performed, showing aortic sclerosis with double aortic lesion, nodular and mobile images that prolapse in diastole to LV outflow chambers of half a centimetre in diameter, indicative of aortic vegetation. Preserved LV systolic function. 2 cm × 1.1 cm image in hypermobile pulmonary valve prolapsing in protodiastole into the right ventricular outflow tract and generating the protodiastolic acoustic vibration described on auscultation.

The case was referred to the Cardiac Surgery Department; due to the context of his haemorrhagic stroke, we decided to wait at least 4 weeks with antibiotic treatment before performing surgery. During his hospitalisation the patient remained stable, aortic and pulmonary vegetations persisted in the control echocardiograms.

A thoraco-abdominal CT scan was performed; the chest showed a small bilateral pleural effusion and a probable repletion defect of 7.5 mm, compatible with vegetation at the level of the aortic valve. Its appearance is rounded and suggests a simple cyst or hamartoma rather than an infarct; multiple diverticula are observed in the colon, and colonoscopy is recommended. In the colonoscopy, diverticula and polyps are found; polypectomy is performed. The results of the pathological anatomy report a tubulovillous adenoma with low-grade dysplasia.

After 4 weeks of antibiotic treatment, the patient underwent surgery.
