A 26-year-old female patient, with no relevant past history, was admitted to the hospital from another institution with a fever of 39°C, arterial hypotension refractory to volume resuscitation, cutaneous hyperaesthesia. The condition had been interpreted as toxic shock, and she was blood cultured and antibiotic treatment was started prior to referral.
On admission to the intensive care unit of our hospital, the patient was confused, tachycardic (120/min), hypotensive (70/40 mmHg) and afebrile. She had painful purpuric lesions on the palms, soles, subungual and periungual region, and on the palpebral conjunctiva, compatible with peripheral embolisms. No heart murmurs were heard. There were no other alterations on physical examination.

Laboratory tests on admission showed plateletopenia (39,000/mm3), 4500 leukocytes/mm3, low prothrombin time (58%) and parameters of Acute Renal Failure (elevated creatininemia). Urine sediment showed albuminuria, microscopic haematuria and granular casts. The rest of the analyses were within normal parameters (haematocrit, hepatogram, HIV negative, b-subunit negative). The fundus examination was normal. Chest X-ray showed cardiomegaly and bilateral interstitial-alveolar infiltrate. The picture was interpreted as septic shock, blood cultures were performed (under antibiotics because he had received 1 dose of cefotaxime/ clindamycin/ amikacin) and treatment was started with cefotaxime/ clindamycin/ gentamicin, after consultation with Infectious Diseases.

On the second day of hospitalisation, the patient persisted with signs of heart failure on chest X-ray, adding bilateral infiltrates of the pulmonary oedema type and compatible semiology, for which a referral to the cardiology department was requested to perform a transthoracic echocardiogram where vegetation was observed in the mitral valve with moderate mitral regurgitation and moderate left ventricular dysfunction. A diagnosis of infective endocarditis was made 24 hours after the patient's admission. Treatment with clindamycin was discontinued.

During her evolution, the patient's haemodynamics worsened, requiring inotropic drugs and her respiratory mechanics required non-invasive ventilation. After several days of antibiotic treatment she continued with febrile registers. A transesophageal echocardiogram was performed which showed an image compatible with mitral annulus abscess. Due to the patient's haemodynamic instability, the cardiovascular surgery department decided not to perform surgery at that time. Four days after admission, the first blood cultures obtained were positive for Staphylococcus aureus, aminoglycosides were discontinued and Vancomycin was indicated.

The patient's haemodynamic and laboratory parameters improved, her renal insufficiency was reversed, the skin lesions disappeared, and after 16 days she was allowed to be transferred to Buenos Aires to continue antibiotic treatment and plan the surgical strategy.
