HISTORY, CURRENT DISEASE AND PHYSICAL EXAMINATION
75-year-old male with a history of arterial hypertension, dyslipidaemia, ischaemic stroke, chronic ischaemic heart disease and aortic biological prosthesis due to severe aortic stenosis 2 years ago, requiring DDD pacemaker implantation due to advanced post-surgical atrioventricular block. She was admitted with fever and a slight increase in her usual dyspnoea in the last 2 weeks, with orthopnoea and paroxysmal nocturnal dyspnoea. On medical history, he denied any associated respiratory infectious symptoms.

Physical examination:
BP 145/62 mmHg, HR 92 bpm, SatO2 98% on room air, Ta 38.2°C. Conscious and oriented. Jugular ingurgitation. Cardiac auscultation: rhythmic without murmurs. Pulmonary auscultation: bibasal crackles. Abdomen: soft, depressible, not painful on palpation, without visceromegaly. Lower limbs: oedema with pretibial fovea ++.

COMPLEMENTARY TESTS
Blood cultures: 4 positive samples for Streptococcus anginosus. Transthoracic and transesophageal echocardiogram: multiple vegetations at aortic level (the largest measuring 10 x 8 mm) and an inhomogeneous thickening, perivalvular and with an echodense appearance corresponding to an abscess of the aortic annulus measuring 3.6 x 2.3 cm. Cardiac CT: in addition to the above, two small pseudoaneurysms were observed at subvalvular level. 18F-FDG PET/CT: pathological deposit of activity around the aortic prosthesis with greater intensity in the posterior region and absence of uptake in the cardiac pacing system.

EVOLUTION
Given the presence of an uncontrolled infection (aortic abscess) the patient underwent valve replacement surgery. Prior to the procedure, a PET/CT scan was performed to assess the involvement of the pacemaker generator and leads and to decide whether or not to replace the pacing system. Given the results of the test, it was finally decided not to remove the pacemaker. Postoperative evolution was satisfactory, antibiotic treatment with ceftriaxone was continued for a further 20 days and follow-up echocardiograms showed no complications. During subsequent clinical visits, the patient did not report fever or dyspnoea.

DIAGNOSIS
Late infective endocarditis on biological aortic prosthesis, due to Streptococcus anginosus, complicated with aortic perivalvular abscess. Valve replacement surgery. Carrier of bicameral pacemaker due to advanced atrioventricular block, with no evidence of infection of the device.
