A 57-year-old woman presented with dyspnoea and fever, diagnosed with infective endocarditis on native valve due to Lactobacillus rhamnosus (a rare bacterium, widely used as a probiotic).

HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

Personal history
No known drug allergies. Toxic habits: smoker of 1 pack/day.
Intervened for pneumothorax more than 15 years ago. Admitted 11 days earlier to the Respiratory Department with the diagnosis of probable moderate COPD and respiratory infection treated with levofloxacin for 7 days with good evolution.
Blood cultures during this admission, positive for Lactobacillus rhamnosus, interpreted by the laboratory as possible contamination. Current treatment: citalopram 20 mg, inhaled glycopyrronium and paracetamol. Baseline functional status: higher functions preserved, works as a shop assistant in a clothing shop. Lives with her husband and children.

Present illness
Progressive dyspnoea of 3 days evolution. Today dyspnoea at rest. 4 days ago, fever peak of up to 37.8°C and pain in right hip which subsided on its own, for which she did not consult.

Physical examination
BP 110/62, HR 115 bpm, Ta 37.7°C, O2 Sat (Ventimask 40 %) 95 %. Tachypnoea of 18 rpm. On inspection, the patient was normal colour, with good hydration of skin and mucous membranes. On cardiac auscultation, the heart is rhythmic, with systolic murmur mitral focus. Pulmonary auscultation shows crackles in the middle and lower fields and scattered wheezing.
The abdomen is soft and depressible, painless on palpation with sounds present.
The lower extremities are free of oedema and the paedial pulses are present and symmetrical.

COMPLEMENTARY TESTS
ECG: sinus tachycardia at 115 bpm.
Chest X-ray: cardiac silhouette at the upper limit of normality.
Laboratory tests: PO2 80 mmHg; PCO2 34 mmHg; pH 7.49; HCO3 25.9 mmol/l; lactate 10 mg/dl. Glucose 112 mg/dl; creatinine 0.63 mg/dl; GPT 15 U/l; Na 137 mmol/l; K 3.99 mmol/l; CK 16 U/l; LDH 194 U/l; CRP 11.29 mg/dl; PCT 0.18 ng/ml. Hb 10.3 g/dl; platelets 207,000/μL; leukocytes 9,200/μL (N 78.5 %). IP 100 %; INR 1.
Transthoracic and transesophageal echocardiogram: the left ventricle is not dilated or hypertrophic, with good global systolic function and hyperdynamic.
The mitral valve shows several images, the largest measuring 19 x 6 mm, compatible with endocardial vegetations. The posterior leaflet shows a large perforation leading to massive regurgitation.
The aortic valve shows an image in the LVOT dependent on the non-coronary leaflet (13 x 6 mm), which appears perforated and there is a significant coaptation defect leading to severe regurgitation in relation to the involvement of the right coronary artery. The right ventricle is not dilated, with good systolic function. No pericardial effusion was observed
Coronary angiography: coronary network without lesions.

EVOLUTION
In view of the findings described above, the patient was admitted to the Coronary Unit, where the TEE was performed. Treatment was started with intravenous ampicillin and gentamicin.
Given that she was admitted with heart failure, she underwent double valve replacement within 24 hours, aortic (Carbomedics Top Hat no. 21) and mitral (Bicarbon Fitline no. 27). The cardiac surgery was uneventful, with an ischaemia time of 102 min and CPB time of 123 min. The surgeon described the following intraoperative findings: warts on the posterior leaflet of the mitral valve, warts on the non-coronary leaflet of the aortic valve with the rings of both valves well preserved.
The specimen was sent to anatomical pathology and microbiology for culture, subsequently confirming infection by Lactobacillus rhamnosus.
He arrived at the Coronary Unit, from the operating theatre, haemodynamically unstable with noradrenaline at 0.2 μg/kg/min, in sinus tachycardia 135 bpm with BP 80/50 mmHg.
Echocardioscopy (V-Scan) was performed, showing severe biventricular dysfunction (estimated LVEF 10%), without pericardial effusion. The findings were confirmed, as well as the normofunction of both prostheses by TEE. Therefore, intensive serum therapy was started and noradrenaline (up to 2 μg/kg/min), dopamine (up to 20 μg/kg/min) and adrenaline (up to 0.4 μg/kg/min) were progressively administered in increasing doses. With this, we achieved a MAP 65-70 mmHg, CVP 18 mmHg, HR 110 bpm, CO 3.2 L/min and IC 2.3 L/min/m2. However, he persisted with oliguria and increasing lividity in the atria and lower extremities in an ascending manner.
Intra-aortic balloon counterpulsation implantation was chosen. Despite counterpulsation (1:1) and the "stability" of haemodynamic parameters, the data of cardiogenic shock with peripheral hypoperfusion were increasing (lactate 10 --> 145 mg/dl; creatinine 0.63 --> 2.19 mg/dl; GPT 15 --> 3,068 U/l). Therefore, veno-arterial ECMO implantation with peripheral access is indicated, guided by TEE, which is carried out successfully.
Subsequently, the patient evolved favourably, with a progressive decrease in the analytical parameters of peripheral hypoperfusion, and the doses of inovasoactive drugs were gradually reduced. Finally, after 14 days, IABP was withdrawn and 24 hours later, ECMO was withdrawn, with good haemodynamic tolerance. After 30 days in the Intensive Care Unit, she was discharged to the hospital ward.

DIAGNOSIS
Infective endocarditis on native mitral and aortic valves due to Lactobacillus rhamnosus, complicated by heart failure.
Mitral and aortic valve replacement surgery.
Cardiogenic shock after cardiac surgery requiring assistance with intra-aortic balloon counterpulsation and ECMO, with good evolution.
