Introduction: Infective endocarditis (IE) is a life-threatening disease of the heart valves that despite modern therapeutic options has a poor prognosis and high mortality. IE occurs more often in patients with acquired or congenital heart disease, and the etiology is usual bacterial. Echocardiography has the key role in establishing the diagnosis. Given the different, often atypical forms of presentation, this complex infectious disease still represents a diagnostic challenge despite the progress of clinical practice. (1-5)

Case report: 47-year-old patient with quarterly intermittent fever and pain in the right hip, was hospitalized becomes because of dry cough and breathlessness at minimal effort that occurred few days before admission. Two months earlier, the patient was treated at the Clinic for Orthopaedic Surgery due to synovitis of the right hip. The emergency echocardiography showed endocarditis of the bicuspid aortic valve with severe aortic and mitral regurgitation. Transesophageal ultrasound demonstrated a paravalvular abscess of the aortic valve that was expanding forward the base of the anterior mitral leaflet. With administration of empirical antibiotic therapy, and after hemodynamic stabilization, the patient underwent emergency cardiothoracic surgery. The biological aortic and mitral valve were successfully implanted. From later received blood cultures, Streptococcus sanguis was isolated.

Conclusion: IE may have a number of different and often atypical clinical presentations. In every prolonged febrile disease course, we should think on IE. Febrile inflammation of the musculoskeletal system of unknown etiology may represent the first manifestation of IE. Patients with congenital heart disease such as bicuspid aortic valve, are at particular risk for the development of IE. Although in this case the bicuspid aortic valve represents a predisposition for the development of IE, the fact that the Streptococcus sanguis endocarditis is more frequently in patients with malignant and inflammatory gastrointestinal diseases bring us to the question on subsequent gastrointestinal treatment in the present case.