HISTORY, CURRENT DISEASE AND PHYSICAL EXAMINATION
The patient is 55 years old, with no known drug allergies and no known cardiovascular risk factors.  Personal history ʟʟ Previous heart disease: dilated cardiomyopathy due to Chagas disease with severe systolic dysfunction and implantation of a single-chamber ICD in 2007 for primary prevention. Regular follow-up in the arrhythmia unit of our department (during follow-up he presented an episode of SMVT that subsided with ATP, without requiring shock). On 24 March 2015 he was admitted to our department for ICD generator replacement.

Other history: sensory, axonal and demyelinating polyneuropathy of moderate degree in the upper and lower extremities.

Chronic treatment: ramipril 5 mg/24 hours. carvedilol 25 mg/24 hours. Sintrom according to guideline. Present illness Patient referred to the emergency department of his reference hospital after being found at home disoriented, confused and with sphincter incontinence by his work colleagues. They went to look for him as he had not been at work for the last three days. Anamnesis impossible to perform on the patient due to his neurological deterioration.

Physical examination
BP: 85/60 mmHg.
HR: 85 bpm.
RR: 26 rpm.
Sat02: 96% with nasal goggles at 2 bpm.
NRL: conscious and oriented in space and person. Lethargic. Fluent language without aphasic components. Pupils isochoric and normoreactive. Left facial paresis. Cranial nerves centred. Preserved strength and sensibility in extremities. Preserved ROTs.
CA: very muffled cardiac tones, no murmurs.
AP: rhonchi in both lung fields. No other superimposed sounds.
Abdomen: soft, depressible, not painful on palpation. No masses or megaliths. No signs of peritoneal irritation.
MMII: No oedema. Pulses preserved.
General: pterygium over the right eye. Ulcer in the wound of the ICD generator in the left subclavian region.

COMPLEMENTARY TESTS
In the emergency department of the hospital, the study began with the extraction of blood cultures due to fever (38.5 °C), and the following complementary tests were performed:
CBC: 9000 platelets, 14,400 leukocytes, INR 10, AP 6.5%, CRP 67.11, procalcitonin 24.4, creatinine 1.77, total bilirubin 6.2 (at the expense of direct). Chest X-ray: increased CTI, hilar congestion with bilateral nodular images.
Cranial CT: hypodensity in right basal ganglia compatible with old lacunar infarcts. Hypodensity in the left parietal convexity compatible with residual ischaemic lesion. No LOES, contusion images or haemorrhage. Ventricular system within normality.
Thoracic-abdominal CT scan: in the mediastinum there were small lymph nodes smaller than 1 cm of doubtful pathological significance. Poorly defined nodular densities can be seen in the lung fields. Although cavitation is not seen, in the clinical context of the patient, the possibility of septic emboli should be considered. Elevation of the right hemidiaphragm. Minimal right pleural effusion/enlargement. Abdomen: normal sized liver with no evidence of focal lesions. Bile duct, pancreas, spleen, kidneys and adrenal glands without significant findings. No free fluid or collections were seen. In view of these findings and with clinical suspicion of severe septic shock, noradrenaline perfusion and empirical antibiotic treatment with imipenem and cloxacillin was started, with poor clinical evolution, and the patient was referred to the ICU of our hospital.

On arrival at the ICU, the following tests were performed:
CBC: sodium 135, K+ 4.5, Cl 101, glucose 187, urea 107, creatinine 1.28, CPK 109, total bilirubin 6.19 (direct 5.86, indirect 0.33), CRP 26, procalcitonin 17.3, Hb 13.1 g/dl, Hto 37.2%, 9000 platelets, 14850 leukocytes, INR 1.53, AP 52%. ECG: RS at 75 bpm. PR 200msg, QRS 80msg with normal axis and low voltages in frontal leads. No acute repolarisation alterations.
Transthoracic echocardiography: dilated LV with apical aneurysm and hypokinesia of the remaining segments, causing moderate-severe systolic dysfunction (LVEF 38%). Trivalve aortic valve, without gradients or pathological flows. Mitral valve with mild central insufficiency. Right chambers of normal dimensions with normal systolic function. LAD cable with abundant hyperechogenic material adhered along its trajectory, with independent movement suggestive of vegetation.
Transesophageal echocardiogram: This study confirmed the previous findings. During his stay in the ICU, antibiotic treatment with daptomycin was continued, new blood cultures were taken and the device was removed (generator and ICD cable, by traction) after 48 hours, and samples were sent to Microbiology:
Blood cultures (x2): isolation of methicillin-resistant S. aureus (resistant to cloxacillin and penicillin). LAD cable: isolation of methicillin-resistant S. aureus.

EVOLUTION
In view of these findings, he was assessed by the Infectious Diseases Department, and the positive blood cultures persisted. Antibiotic treatment was adjusted and he was finally placed on vancomycin, fosfomycin and linezolid. In the following days, a repeat chest CT scan confirmed the presence of septic pulmonary emboli, bilateral pleural effusion and associated compressive atelectasis. And the transesophageal echocardiogram was repeated, which showed a mass attached to the posterior tricuspid leaflet measuring 33x18 mm, hypermobile and with anchorage that progressed to the subvalvular apparatus, with another smaller vegetation on the free edge of the septal leaflet. No pulmonary, mitral or aortic valve involvement. Antibiotic treatment was continued in the following weeks, with progressive normalisation of renal and hepatic function parameters, coagulation and inflammatory markers. Cardiac MRI was requested, which confirmed biventricular dilatation with moderate systolic dysfunction and the presence of an apical aneurysm. A new chest CT scan showed resolution of the septic embolisms; and the various echocardiographies performed showed no persistent valve vegetation. Once antibiotic treatment was completed, and the patient remained clinically stable, a new single-chamber ICD was implanted on the contralateral side without incident.

DIAGNOSIS
Severe septic shock secondary to infective endocarditis due to methicillin-resistant S. aureus.
Dilated cardiomyopathy of chagasic aetiology. Severe systolic dysfunction. ICD carrier in primary prevention.
Explant and reimplantation of single-chamber ICD.
