A 53-year-old man presented to the emergency department complaining of pain in the left iliac fossa of 6 h-duration, along with fever, nausea, anorexia and general fatigue, though without cardiovascular manifestations. He had undergone mitral annuloplasty with a 24-mm ring for posterior mitral valve prolapse 4 years earlier, followed by further mitral valve repair for recurrent mitral regurgitation (MR). The histopathological examination had then revealed no IE, but severe myxomatous degeneration of a mitral tendon, thought to have caused the rupture of a mitral chordae and precipitated MR. After surgical repair, the patient chose to leave the hospital prematurely despite the persistence of a low-grade fever. When he returned, 2 months later, his examination revealed a clear mental status, a body temperature a 37.6 °C, a blood pressure at 87/55 mmHg, and a heart rate at 85 bpm. The percutaneous oxygen saturation on room air was 95 %. He had no audible pathologic heart murmur, no manifestation of cardiac decompensation and no sign of thromboembolism. The abdomen, however, was slightly distended, with a painful left iliac fossa and rebound tenderness on palpation. The white blood cell count was 25.2 × 103/mm3 (granulocytes 88.9 %, lymphocytes 3.5 %) and 235 × 103/mm3 platelets, the blood haemoglobin concentration was 11.1 g/dl, and C-reactive protein concentration was 6.36 mg/dl. A plain film of the abdomen showed dilated small and large bowels with niveau formation. A tentative diagnosis of ileus was made initially by consultant gastroenterologists. An abdominal computed tomography with contrast showed low-density areas within the liver, spleen and both kidneys, prompting the patient’s referral to a cardiologist for evaluation of multiple embolisms, putatively caused by IE. Transthoracic echocardiography detected no significant MR, though mitral valve thickening was present, which was not observed after the previous mitral valve repair. The left ventricular end-diastolic and end-systolic diameters were 47 and 31 mm, respectively and ejection fraction was 63 %. A transoesophageal echocardiogram was performed, which revealed a prominently mobile vegetation and dehiscence of the annuloplasty ring from the anterior mitral annulus. Despite a separation of the ring from the anterior aspect of the mitral annulus during diastole, no significant MR was observed. The anterior dehiscent part of the annuloplasty ring was located in the middle of the mitral orifice and consecutively in touch with the anterior leaflet, not the anterior annulus, during systole, when the leaflets were pushed towards the atrium. Accordingly, during diastole, the leaflet opened towards the ventricle and the annuloplasty ring remained in its position, detached from the leaflet. Active IE was diagnosed as the cause of multiple embolisms and septicaemia. Intravenous gentamicin, 40 mg t.i.d, and ampicillin, 1.5 g b.i.d, were administered immediately after the admission. Brain computed tomography and magnetic resonance imaging showed neither cerebral infarction nor aneurysm. After the patient’s admission to the cardiovascular surgery department, his body temperature rose to 39.4 °C. He underwent mitral valve replacement 2 days later for management of annuloplasty ring dehiscence, impending recurrent embolization and uncontrolled infection. Intraoperative inspection confirmed the presence of a dehiscent anterior portion of the mitral annuloplasty ring. High- and low-power histopathologic microphotographs showed the destruction of the three layers of the anterior mitral leaflet, with Gram positive cocci along with severe inflammation and necrosis of the valvular tissue. All the blood cultures were positive for coagulase-negative staphylococcus capitis, consistent with the histopathology. Four days after the surgery, intravenous ampicillin was replaced with vancomycin, 0.5 g t.i.d because of resistance to ampicillin. The postoperative course was uneventful with resolution of the manifestations of abdominal disease without further treatment and, over a follow-up of 18 months, the patient remained free from recurrence of IE.