A 38-year-old patient from Luque, a dressmaker, known to be hypertensive and on irregular treatment with Losartan 50 mg/day. Obstetric and gynaecological history of three pregnancies, two births, one stillbirth and refers that her mother has been a carrier of arthritis since the age of 50.She reports a clinical picture of terebrante pain located in the interphalangeal joints radiating bilaterally and symmetrically to the wrist with signs of inflammation and functional impotence, predominantly in the morning, of 11 months of evolution; three months before admission, a feverish sensation was added to the picture, predominantly at night with profuse sweating accompanied by progressive dyspnoea, first on moderate exertion and then on mild exertion. Three weeks before admission, pain with the same characteristics migrated to the left ankle and became bilateral and symmetrical, and did not subside with common analgesics. Two weeks before admission, due to the persistence of the symptoms, she consulted a doctor who requested complementary studies and found a sudden drop in haemoglobin levels, and indicated referral to the Haematology Department.Two days before admission to the department, the symptoms (arthralgias, fever and dyspnoea) were exacerbated and the patient went to the emergency department where she was assessed by a haematologist who requested additional tests. Subsequently, the patient was admitted to the ward with the following laboratory results. Data of value on physical examination were: On ectoscopy, dyspnoeic fascies, pallor of skin and mucous membranes; in the respiratory system, poor respiratory mechanics, tachypnoea, dyspnoea, on percussion, dullness in both bases, on auscultation, subcrepitant in both midfields, abolished in both bases; in the cardiovascular system, heart sounds with regular rhythm, tachycardia, R1 and R2 hypophonetic, no galloping, diastolic murmur in aortic focus and holosystolic in mitral focus with irradiation to the axilla; abdomen soft, depressible, not painful, slight splenomegaly, no palpable hepatomegaly; in the osteoarticular system, inflammatory signs at the level of the right knee. No inflammatory signs in other joints. Based on these data, the following diagnoses were proposed: left heart failure, mitroaortic insufficiency, collagenopathy to be confirmed, anaemic syndrome, controlled arterial hypertension. In the following days the patient presented febrile peaks and polycultures were performed. A volume of concentrated red blood cells was transfused and the patient's dyspnoea worsened, having previously returned a negative direct Coombs' test. A simple CT scan of the chest showed a diffuse interstitial pattern with bilateral pleural effusion in both bases, and so, with the possibility of collagenopathy, boluses of methylprednisolone (5 grams) were started, to which she responded favourably. Rheumatological profiles were requested (ANA, anti DNA, anti CCP, C3, C4, Anti B2 glycoprotein, Antiphospholipid, Anticardiolipin, Lupus anticoagulant, Antithrombin III, Prot.C and S) which all returned in the normal range except FR in dilution 1/512. A transthoracic echocardiogram was performed, showing vegetation on the aortic and mitral valves, with pseudoaneurysm of one aortic and one mitral leaflet, as well as perforation of one aortic leaflet, which led to a diagnosis of endocarditis and empirical antibiotic therapy was started immediately, even though the laboratory tests returned with few variations. Days later, blood cultures returned positive for Streptococcus alpha haemolyticus in 3 of 8 bottles. Subsequently, the patient underwent bivalvular replacement with mechanical valves, which was successful. She returns the results of the pathological anatomy of the vegetations which reports the following: "Cardiac valves with marked degenerative changes (fibrosis, hyalinisation and myxoid changes). There are also numerous reactive fibroblasts, some of them with changes suggestive of previous rheumatological pathology. On the surface there is a marked acute inflammatory infiltrate and fibrin deposits corresponding to vegetations. The histological findings are compatible with acute bacterial endocarditis"

The definitive anatomopathological diagnosis is Acute Bacterial Endocarditis due to the visualisation of Anitschkow cells, which due to the chronicity of the symptoms is clinically presumed to be Subacute Bacterial Endocarditis, with suspected comorbidity, a collagenopathy to be confirmed with subsequent follow-up
