Case Presentation: Prosthetic valve endocarditis (PVE) is predominantly caused by staphylococcus aureusand streptococcus viridian. Infective endocarditis (IE) due to Burkholderia cepacia israre. We present a case of a 27-year-old man with history of injection drug use, IE of aorticand mitral valve status post replacement with bioprosthetic valves 6 months ago, whopresented with fever, chills, dyspnea and lightheadedness for three days. He wasafebrile, hypotensive (97/51 mmHg) and tachycardic (147 bpm) on presentation.Cardiovascular exam revealed a grade 3/6 systolic murmur at the left sternal border.Vancomycin and cefepime were started empirically after obtaining blood cultures. TTEdemonstrated reduced ejection fraction (EF 25-30%). TEE confirmed 1.8 x 1.2 cmvegetation on posterior leaflet of mitral valve causing functional mitral stenosis.Gentamicin and rifampin were added to treat PVE. Blood cultures were positive at 21.39hours for gram negative rods. On day 5, Burkholderia cepacia sensitive to levofloxacin,meropenem, and trimethoprim/sulfamethaxozole and resistant to ceftazidime wasidentified. Antibiotics were changed to meropenem and levofloxacin. Blood culturesbecame negative two days after the antibiotics change and remained negative on bloodculture drawn 10 days post discharge. Cardiothoracic surgery was consulted whodeemed him a nonsurgical candidate because of his acute biventricular failure. He wasdischarged on meropenem for 8 weeks and life-long suppressive levofloxacin.

Discussion: Burkholderia cepacia is an opportunistic pathogen that causes respiratory illness andbacteremia particularly in patients with cystic fibrosis or chronic granulomatous disease.The treatment of Burkholderia cepacia endocarditis consists of administration ofantibacterial agents, and/or surgery. Our decision to start levofloxacin and meropenemwas based on IDSA guidelines which encourages use of double gram-negativecoverage for endocarditis due to non-HACEK gram-negative bacilli. Vegetations leadingto mitral valve stenosis is a rare complication, and is an indication of the surgery, butwas not pursued due to patient’s condition.

Conclusions: Burkholderia Cepacia endocarditis is a rare cause of prosthetic valve endocarditis associated with IV drug use. Current guidelines regarding treatment of endocarditis by Non-HACEK gram negative bacilli like B. cepacia suggest using combination therapy with a beta-lactam and either an aminoglycosides or combination flouroquinolones. However, given B. cepacia high rates of antibiotic resistance, treatment decision must be guided by culture sensitivities.