Introduction: Infective endocarditis remains life-threatening disease with in-hospital mortality of 15-30%. This entity represents complex interaction between pathogen, host immune system and coagulation cascade. (1-3) However, routine anticoagulation therapy in this setting is not recommended by the official guidelines.

Case report: Patient with bioprosthetic aortic valve was admitted for abdominal pain and elevated inflammation markers. Artificial valve vegetations were confirmed by transesophageal echocardiography and CT abdominal scan revealed spleen and right kidney infarctions. Streptococcus viridans was isolated from blood cultures and was sensitive to empirical gentamycin and vancomycin. Repeated transesophageal echocardiogram (TEE) showed no residual vegetations and patient was dismissed on the 26^th day with oral amoxicillin. 6 days later patient came again complaining of similar abdominal pain but with normal blood tests and no fever. Repeated CT scan revealed reinfarction of spleen and no residual changes on kidneys. TEE was preformed once again this time showing 6x6 mm floating mobile mass of the same valve highly suspicious of thrombus. Patient was dismissed after 4 days but this time with warfarin.

Conclusion: This case reminds us of need to individualize therapy for each patient. There is perhaps underrecognized need for more liberal use of anticoagulation therapy especially in high risk patients early in the course of the disease.