The patient was a 72-year-old white man with a history of apparent health and no evidence of previous valvular heart disease who 2 months prior to admission began to present with fever and weakness, with general malaise and dyspnoea on exertion. The fever was never higher than 39oC and usually appeared in the afternoons. Initially it subsided quickly with the usual antipyretic measures, but became more persistent until it appeared for 10 to 12 hours a day. In his health care area it was interpreted as a fever of unknown origin until leukocytosis and accelerated erythrocyte sedimentation were observed. Without specifying the cause, treatment with penicillin was started and on the fifth day amikacin was added as the desired improvement was not achieved. He was then referred to our centre for an echocardiogram and on physical examination we found a III/VI sitolic murmur at the tip radiating towards the axilla with a small diastolic murmur, hepatosplenomegaly and the presence of crepitant rales in both lung bases.
A transthoracic echocardiogram revealed the presence of a mass on the posterior mitral leaflet compatible with endocardial vegetation. We then decided to admit the patient with the diagnostic impression of IE, took samples for blood cultures and started treatment with vancomycin and gentamicin, considering the possibility of Staphylococcus aureus as the causative agent, but the fever persisted, the patient's clinical condition worsened and we received 8 negative blood cultures.
We took samples to use special culture media and found the presence of Candida albicans, so we started treatment with amphotericin B, but, although the fever decreased, the haemodynamic status did not improve and we decided to perform surgery.
The patient underwent mitral valve replacement without complications, and a mechanical bidisc prosthesis was used. The pathological examination confirmed the diagnosis.
The patient completed his hospital course of amphotericin B and was discharged on oral ketoconazole, in addition to digitalis, diuretics and anticoagulants.
