A 69-year-old man with an asymptomatic right ureteral stone presented to the hospital with a chief complaint of fever that had begun one week earlier. He took no oral medications, had a 100-pack-year smoking history, and consumed 350 mL/day of beer. He had no allergies or significant family history. He had worked for many years in the tuna brokering business but had retired several months earlier and was currently unemployed. Six days before his visit, the patient developed redness and pain in the left anterior thoracic region and had difficulty raising his left arm. The day before the visit, he experienced gross hematuria and was prescribed sitafloxacin at a nearby clinic for a suspected urinary tract infection. On admission, the patient was conscious, with a Glasgow Coma Scale score of E4V5M6, temperature of 38.1°C, blood pressure of 140/80 mmHg, pulse of 99/min, respiratory rate of 28/min, and oxygen saturation of 99% (nasal cannula, 1 L/min). Physical examination revealed redness, hot tenderness, fluctuant swelling, and bulging in the left anterior thoracic region. Peripheral signs suggestive of infective endocarditis were observed. No crackles were heard on auscultation, and there was no spinous process tenderness. Laboratory findings revealed the following: white blood cell count, 22,700/μL (neutrophils, 90.5%; lymphocytes, 5.5%; monocytes, 3.0%) (normal range: 3,300–8,600/L); creatinine, 0.85 mg/dL (normal range: 0.65–1.07 mg/dL); total protein, 6.9 g/dL (normal range: 6.6–8.1 g/dL); lactate dehydrogenase (LDH), 269 U/L (normal range: 124–222 U/L); glucose, 162 mg/dL (normal range: 73–109 mg/dL), and C-reactive protein, 37.8 mg/dL (normal range: 0.00–0.14 mg/dL). Urinalysis revealed occult blood 2 + and leukocytes 1 +. Chest radiography revealed an infiltrative shadow in the left upper lung field, and contrast-enhanced computed tomography (CT) showed fluid accumulation with marginal contrast enhancement around the sternocostal joint of the left first rib, extending subcutaneously. This image findings were consistent with EN. A small-bore chest tube was inserted at the same site, and purulent turbid drainage was obtained. Pleural fluid revealed a pH of 6.9, total protein of 3.9 g/dL, LDH of 3,561 U/L, glucose of 25 mg/dL, adenosine deaminase of 87.1 U/L, and total cell count of 24,900/μL (neutrophils, 98%; monocytes, 2.0%). On the same day, ampicillin/sulbactam 3 g every 6 h was started; on the second day, vancomycin (VAN) 1.25 g every 12 h was added because Gram-positive cocci in clusters were observed in the Gram stain from the blood and pleural fluid collected on admission. Acid-fast bacilli smear, culture, and polymerase chain reaction of the pleural fluid specimen were all negative. The serum trough concentration of VAN was 15–20 mg/L. On the third day, a chest radiography revealed that the infiltrative shadow in the left upper lung field was reduced; however, an infiltrative shadow in the left lower lung field appeared, and a drain was added at the site. On the fourth day, the final culture revealed MRSA in the blood and pleural fluid at the time of admission. This was confirmed using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (Bruker Biotyper, Bruker Daltonik GmbH, Bremen, Germany). The susceptibility test was performed using the MicroScan Walkaway Plus automatic system (Beckman Coulter, USA). A blood culture obtained on day 6 also showed persistent positivity; therefore, daptomycin 700 mg (9 mg/kg) was added every 24 h. Blood cultures obtained on day eight yielded negative results. Transthoracic echocardiography was performed twice, with one week interval, with no findings suggestive of infective endocarditis. On day 10, drainage from the chest tube was decreased, and the shadows on the chest radiograph improved; therefore, the chest tube was removed. Thereafter, the fever resolved; however, on the 17th day, the patient had fever with neck pain, and contrast-enhanced magnetic resonance imaging (MRI) revealed contrast enhancement of the vertebral body and perivertebral space at C7–T1, which led to the diagnosis of vertebral osteomyelitis. No epidural abscess was observed. The patient clinically improved and was discharged from the hospital on the 28th day because the fever gradually resolved, cervical pain tended to improve, and the antimicrobial agent was changed to oral linezolid 600 mg every 12 h. Taste disturbance due to linezolid was observed; however, chest radiography revealed a decrease in pleural effusion, and the treatment was terminated on day 58. In retrospect, the erythrocyte sedimentation rate (ESR) at this time was 80 mm/h. On day 67, the patient again presented with neck pain and fever, and contrast-enhanced CT revealed enhanced soft tissue shadows around the C7–T1 vertebral body. He was readmitted with a diagnosis of a flare-up of vertebral osteomyelitis. Therefore, we restated VAN. There was no worsening of pleural effusion on chest radiography. The patient continued VAN for 14 days and was then switched to oral sulfamethoxazole–trimethoprim (SXT) 160 mg/800 mg every 12 h. On day 125, due to elevated liver enzyme levels, the patient was administered daptomycin for three days. The enzyme levels quickly normalized and were elevated only once during this period. Subsequently, the treatment was switched to oral minocycline 100 mg every 12 h. After confirming that the ESR had normalized, treatment was terminated on day 215. No relapse has occurred since then.