Culture negative endocarditis: a diagnostic and therapeutic challenge!

Infective endocarditis remains a diagnostic and therapeutic challenge. The authors report an older male who presented with a lower extremities rash and signs of cardiac failure. Echocardiography showed vegetations attached to the bio-prosthetic aortic valve, however, with negative blood cultures. Further investigation revealed positive Bartonella serologies. The patient was diagnosed with Bartonella endocarditis affecting the prosthetic valve and started on appropriate antibiotics. Valvular surgery was refused by patient secondary to age and medical co-morbidities. The patient presented 10 days later with intracerebral haemorrhage and progression of the endocarditis as demonstrated on echocardiogram. Valve replacement was contraindicated at this occasion due to the intracerebral bleed. The patient had poor prognosis and a decision to withdraw care was made by the family. The authors demonstrate a case of complicated infective endocarditis caused by Bartonella species leading to multisystem involvement. This case highlights the need for urgent valve replacement in the setting of Bartonella endocarditis.