Background
No known allergies. Glaucoma. Knee arthritis, under treatment with corticoids, attended acupuncture treatment for pain management. No CVRF. Present illness The patient attended the Emergency Department for low back pain and was discharged the same day with a diagnosis of low back pain and normal complementary tests (blood tests, spinal X-ray). Seven days later, she returned to the Emergency Department with generalised asthenia, fever (not quantified at home), stiff neck and back, papular lesions on the lower limbs, pain and redness in the left knee, weight loss of 8 kg in 3-4 months, associated with general malaise. She was admitted to the Infectious Diseases Department, with initial suspicion of meningitis, for which empirical antibiotic treatment was started with ceftriaxone and vancomycin. A CT scan of the brain, lumbar puncture and synovial fluid were performed. In view of the negative results and progressive worsening of the patient, an assessment by Cardiology was requested on suspicion of bacterial endocarditis, a diagnosis confirmed by echocardiogram and positive blood cultures.

Physical examination
On arrival at the ED: Ta 38°C, BP 130/80 mmHg, SatO2 95% on room air, HR 115 bpm. Good general condition. Conscious and oriented. Neck: marked stiffness on movement. Cardiac auscultation: rhythmic heart sounds, no murmurs. Pulmonary auscultation: preserved vesicular murmur. Extremities: slight peripheral oedema, red nodular lesions, 3 mm in diameter, on the lower extremities. Kerning and Brudzinski: negative.

COMPLEMENTARY TESTS
CBC in the ED: leukocytes 28,500 /uL, neutrophils 97 %, Hb 13.9 g/dl, HtO 41.7 %, platelets 159,000 /uL, glucose 163 mg/dl, urea 61 mg/dl, creatinine 0.54 mg/dl, Na 130 mEq/l, K 3.9 mEq/l, CRP 33.86 mg/dl. CSF culture: negative. Blood culture: Staphylococcus aureus, sensitive to methicillin. Thoracic-abdominal CT scan: bilateral pleural effusion with bilateral basal passive lung collapse. No significant alterations were identified in the rest of the lung parenchyma. Mild splenomegaly of 122 mm. Small peripheral hypovascular areas of triangular morphology suggestive of small infarcts. There are two small 15 mm accessory spleens adjacent to the lower pole. Small retroperitoneal, retrocrural and left external iliac chain lymphadenopathies. The size and morphology of the kidneys are preserved. Cortical cyst of 28 mm in the upper pole of the left kidney. Abdominal aorta of normal calibre. Diffuse increase of intestinal pneumatization. Redundant colic frame, with abundant faeces inside. Small amount of free fluid in the small pelvis. In view of progressive deterioration of general condition and suspicion of septic embolism both in the spleen and lower limbs, plus positive blood culture with no response to treatment, it was decided to transfer her to the ICU and she was assessed by TTE and TEE. Transthoracic echocardiogram: non-dilated LV with normal wall thickness. Preserved LVEF, no segmental asymmetries of contractility. Diastolic pattern of impaired relaxation. RV of normal size and function (TAPSE 21 mm). Aortic valve: mobile pedunculated image up to 2 cm in length prolapsing in LVOT that seems to depend on the left coronary leaflet/mitro-aortic junction, with some other small image of lesser length over the leaflets. No valvular restriction and mild reflux. No images of abscesses over the aortic root by this access route. Mitral valve: anterior leaflet slightly thickened, with no clear images of vegetations on the leaflets. Central reflux in the form of several grade II jets. Tricuspid valve with suboptimal visualisation, no apparent images of endocarditis, no insufficiency. Prominent Eustachian valve. Slight pericardial effusion of about 5-6 mm, mild collapse of the RA. No other signs of haemodynamic compromise. Non-dilated IVC with normal collapse. Transesophageal echocardiogram: LV of normal size and wall thickness. Good systolic function and no contractile asymmetries. On the ventricular wall adjacent to the antero-lateral mitral commissure and in relation to the proximal mitral subvalvular apparatus, a thick mass of anarchic movement of at least 2 cm in length is visualised, which is introduced in its movement towards the LV outflow tract, reaching the VAo plane (touching the ventricular side of the right coronary leaflet). Mitral valve: thin leaflets, without calcium and without apparent alterations in its kinetics. On the atrial side of P1-A1 there are several images of anarchic movement, the largest of approximately 1 cm. Slight central reflux and another that seems to originate from a small perforation of the posterior leaflet, at the level of P1. Aortic valve: trivalve, with thin leaflets without apparent images suggestive of vegetations on the leaflets. In the right coronary sinus there is a hypoechoic mobile image that seems to be a false image/reverberation of the mass coming from the ventricular wall. Slight reflux of central origin and eccentric jet towards the AIS. There are no images suggestive of abscesses or other complications on the root or mitro-aortic junction. No fistulae to the right chambers. Right chambers not dilated. Good RV function. On the lateral wall of the RA and about 2 cm from the tricuspid valve plane, there was a thick mass with similar characteristics to the one seen on the ventricular wall, very long (almost 3 cm long) and with an anarchic movement towards the tricuspid plane. It is introduced in its movement in the valvular plane without producing any alteration in valvular function. From transgastric access, the leaflets of the TV are thin, with no apparent images suggesting vegetations on them. IT is not adequately visualised to estimate PAPs. Pulmonary valve with thin leaflets and no images suggestive of vegetations. Slight pericardial effusion with no evidence of haemodynamic repercussions.

EVOLUTION
The patient presented progressive deterioration of general condition. Blood pressure figures were adequate, although she was tachycardic, tachypneic, with a poor general appearance, so she was transferred to the ICU, where antibiotic treatment was modified, replacing vancomycin with daptomycin, and emergency surgery was performed. She arrived in the operating theatre hypotensive, tachypnoeic and cloudy, with haemodynamic instability throughout the surgical procedure, requiring the infusion of vasoactive drugs (noradrenaline, dobutamine, vasopressin) at high doses, associated with significant intraoperative coagulopathy. Surgical findings included: vegetation in the free wall of the RA approximately 3 cm long; vegetation in the posterior wall of the LV, which protruded through the aortic valve; trivalva of thin, non-calcified leaflets; impacting with the same at the level of the non-coronary leaflet, with minimal changes in the leaflet. It was decided to replace the valve with a mechanical prosthesis. Mitral subvalvular abscess, at the level of the anterior commissure, lateral to LV vegetation, with the need for reconstruction of the tissue, using prolene stitches supported by a Teflon patch. Perforation of fine mitral leaflet, without calcium, with small vegetations in the leaflet, valve replacement by mechanical prosthesis was performed. In the immediate postoperative period, haemodynamic instability persisted. On examination, transient right anisocoria was detected, so a window of sedation was performed where he presented tonic-clonic crises, so sedation was restarted, anti-combustion treatment, and no haemorrhagic or ischaemic signs were observed in the cranial CAT scan. He presented progressive and rapid multi-organ deterioration, with acute renal failure requiring renal function replacement therapy by haemofiltration and haemodynamic failure. In the presence of bilateral mydriasis arreactiva, sedation was withdrawn and the clinical examination and EEG were compatible with brain death. Vasoactive drugs were withdrawn and the patient died.

DIAGNOSIS
Mural endocarditis and valvular endocarditis on native mitral valve due to Staphylococcus aureus. Septic embolisms. Heart failure. Emergent surgery. Poor postoperative evolution with multiorgan failure and exitus.
