We present the case of an 81-year-old man with no known previous heart disease who was admitted to our department for dyspnoea and oedema in the lower limbs.

HISTORY, CURRENT DISEASE AND PHYSICAL EXAMINATION

Personal history
HYPERTENSION. Dyslipidaemia. Diabetes Mellitus type II. Morbid obesity.
COPD.
SAHS in treatment with CPAP.
Benign prostatic hyperplasia.
Episode of deep vein thrombosis in the right lower extremity.
Usual treatment: torsemide 10 mg (1-0-0), valsartan/hydrochlorothiazide 160/12.5 mg (1-0-0), simvastatin 10 mg (0-0-1), metformin 850 mg (0-1-0), doxium 500 mg (1-0-1).

Present illness
The patient was admitted from the Emergency Department with slowly progressive dyspnoea for approximately two months, until minimal effort, together with oliguria and oedema in the lower extremities.
A week ago he presented a catarrhal condition consisting of nasal congestion, cough and whitish expectoration, for which reason he attended his health centre, increasing diuretic treatment and starting empirical antibiotic treatment with amoxicillin-clavulanic acid 875/125 mg for a week. With little improvement of the symptoms after 5 days of treatment, she went to the emergency department.

Physical examination
BP 160/80 mmHg, HR 71 bpm, SatO2 92 % on room air, Ta 36.7°C. Conscious and oriented in time and place. Obese. Well hydrated, good peripheral perfusion. Slight tachypnoea at rest, no signs of work of breathing. Jugular venous pressure not measurable.
AC: muffled cardiac tones with no clear murmurs. PA: crackles in both bases. Abdomen globular, depressible, without pain on palpation. Extremities with oedema with fovea up to the root of the thighs, signs of chronic venous insufficiency.

COMPLEMENTARY TESTS
ECG: atypical atrial flutter with controlled ventricular response at 75 bpm.
HRBBB with secondary repolarisation alterations.
Laboratory tests on admission: glucose 92 mg/dl, urea 60 mg/dl, creatinine 1.6 mg/dl, albumin 3.76 g/dl, liver function normal, sodium 145 mmol/l, potassium 3.81 mmol/l, CRP 0.6 mg/ml, haemoglobin 12.9 g/dl, leucocytes 5,200 10^3/μL (N 52.8 %), platelets 128,000 10^3/μl.
Chest X-ray: no cardiomegaly. Bilateral pleural effusion.
Transthoracic echocardiogram: non-dilated LV, hypertrophic, with good global and segmental systolic function. Mitral valve with slight ring calcification and mild-moderate regurgitation. Aortic root not dilated. Thickened aortic valve, with an image of intermediate echogenicity, without being able to rule out endocardial involvement, with maximum and mean gradient of 50 and 26 mmHg respectively. Moderate-severe AoI. TEE is recommended for better assessment of these findings. Moderately dilated LA. Right chambers not dilated, RV with good function. Mild tricuspid regurgitation with Vd-Ad gradient of 34 mmHg. Estimated PsAP of 40 mmHg. No pericardial effusion.
Transesophageal echocardiogram: thickened aortic valve with points of calcification, with severe regurgitation (IV/IV) with an image compatible with perforation at the level of the non-coronary leaflet. Small mobile image in the LVOT, somewhat hyperechogenic, measuring 0.7 x 0.3 cm, dependent on the leaflet.
Mitral valve with mild-moderate regurgitation without pathological images.

EVOLUTION
During his stay on the hospital ward, intravenous depletive treatment was started with slowly progressive improvement of the congestive signs.
After a first episode of heart failure, a transthoracic echocardiogram was performed followed by a transesophageal echocardiogram with the findings described, compatible with endocarditis. The Infectious Diseases Department was contacted for an interdisciplinary assessment of the condition. Despite the atypical nature of the symptoms, panbacterial PCR was requested, as well as blood and urine cultures, empirical treatment was adjusted for possible endocarditis (ampicillin + cloxacillin + gentamicin) adjusted to renal function and a new transesophageal echocardiogram was scheduled for follow-up, in which no significant differences were observed with respect to the previous study.
During the following days, the cultures collected (blood and urine cultures) were negative and, despite increased intravenous diuretic treatment, the patient recorded a significant weight gain and worsening of oedema in the lower limbs with the appearance of phlyctenas, so given the unfavourable evolution of the condition, the case was discussed with Cardiac Surgery, who decided to perform aortic valve replacement with a biological prosthesis, maintaining antibiotic treatment while awaiting the microbiological results of the extracted heart valve.
Among the analyses requested, the serology for Coxiella burnetti was positive, with high titres, allowing a diagnosis of endocarditis due to Q fever, so the antibiotic treatment regimen was modified and the patient was started on doxycycline + hydroxychloroquine, and he was discharged from hospital.
During the months following discharge, the patient presented several episodes of decompensation of heart failure with bilateral pleural effusion, which required hygiene and dietary educational measures, intravenous depletive treatment, thoracentesis and inclusion of the patient in the heart failure telemonitoring programme, and he is currently in a situation of clinical stability with regular controls by the Cardiology and Infectious Diseases outpatient clinics.

DIAGNOSIS
Endocarditis due to Q fever on native aortic valve.
Aortic insufficiency due to perforation of the non-coronary aortic leaflet.
Secondary congestive heart failure.
Aortic valve replacement surgery for biological prosthesis.
