Introduction: High suspicion for infective endocarditis is driven by fever and positive blood cultures in the absence of an alternative focus of infection. (1, 2) This case underlines the importance of exploring other more obvious sources of bacteremia to avoid unnecessary tests and delays in diagnosis. In cases of inconclusive echocardiography results, imaging should be repeated.

Case report: 59-year-old patient with diabetes and hypertension was admitted for sepsis, unilateral leg pain and plantar rash. Medical history includes aortobifemoral reparation of infrarenal aortic aneurysm 19 years ago and recurrent leg abscesses with prolonged periods of antimicrobial and probiotic therapy. Blood cultures found Lactobacillus rhamnosus and Candida glabrata. Positive blood cultures and clear Janeway lesions (Figure 1) indicated transesophageal echocardiography (TEE) which showed competent aortic valve with small hyperechogenic lesion (7mm X 6 mm) on base of left coronary cusp (Figure 2). TEE was repeated after 2 weeks of effective antimicrobial therapy, showing no change of suspected valvular lesion. Patient clinically improved and repeated blood cultures were negative. Further workup (including FDG-PET/CT) found intensive tracer uptake in the region of implanted aortic prosthesis. The surgeon opted for prolonged course of antimicrobial therapy. Unfortunately, only 4 days after completion of therapy the patient was septic with positive blood cultures. The operation was inevitable and aortointestinal fistula, graft infection and thrombosis were found. Partial graft replacement and bowel reconstruction were conducted.

Conclusion: Even in patients with highly specific findings for endocarditis like skin lesions and positive blood cultures, workup and therapy should be clinically guided. Bizarre blood culture isolates in our patient are easily explained when we know complete course of disease.