Case Presentation: We present a case of a 54-year-old male with history of severe Aortic Insufficiency s/p Bioprosthetic aortic valve replacement (February, 2025), Chronic kidney disease, Congestive Heart Failure with reduced EF (30-35%), and Severe periodontal disease who presented with progressive fatigue, dyspnea and worsening leg edema concerning for prosthetic valve endocarditis (PVE). Transesophageal Echocardiogram demonstrated aortic root abscess with perforation, severe regurgitation, and prosthetic valve rocking. Routine blood cultures remained negative. He was started on empiric intravenous Vancomycin/Cefepime and later switched to Daptomycin/Meropenem for broad coverage prior to surgical intervention pending medical optimization.Hospital course was complicated by clinical decompensation, pancytopenia, recurrent GI bleeding, renal failure requiring CRRT, diffuse bullous rash, found to be leukocytoclastic vasculitis on biopsy and severe malnutrition. Bone marrow biopsy was performed to work up his pancytopenia, revealing non-necrotizing granulomas without malignancy. On day 23 of hospitalization, AFB blood cultures speciated M. Tuberculosis. Karius plasma microbial cell-free DNA testing also detected M. Tuberculosis. Sputum AFB smears were negative, but one culture later grew M. Tuberculosis. RIPE therapy (Rifampin, Isoniazid, Pyrazinamide, Ethambutol) plus Moxifloxacin was initiated. Pyrazinamide and rifampin were held due to hepatotoxicity. He remains critically ill on Isoniazid, Ethambutol, Moxifloxacin, and Pyridoxine. Cardiothoracic surgery deferred surgical intervention pending improved clinical status. Prognosis remains guarded.
Discussion: M. Tuberculosis Prosthetic Valve Endocarditis accounts for < 1% of infective endocarditis and typically presents subacutely with culture-negative results. Aortic root abscess and prosthetic valve dehiscence are reported but rarely confirmed antemortem. This case is further complicated by disseminated TB involving bone marrow, generating granulomas, pancytopenia, and by leukocytoclastic vasculitis, likely immune-mediated in the setting of disseminated M. Tuberculosis. Diagnosis required integration of imaging, AFB blood cultures, and cell-free DNA sequencing. This patient did not have any risk factors for M.tuberculosis. HIV was negative. No history of incarceration, travel to TB endemic areas or illicit drug use. There are few reports of prosthetic valve endocarditis (PVE) due to non-tuberculous mycobacteria (NTM). Prosthetic valve causing disseminated MTB infection is exceeding rare. Medical therapy alone is often insufficient and combined anti-TB therapy with surgical intervention offers the best prognosis. However clinical decompensation, multiorgan dysfunction and malnutrition often annihilate surgical candidacy.
Conclusions: This case highlights disseminated Mycobacterium Tuberculosis as a rare but critical cause of culture-negative prosthetic valve endocarditis and valve abscess. Early consideration of TB in subacute Prosthetic Valve Endocarditis, use of newer molecular diagnostics testing, and multidisciplinary management are essential. Timely surgical intervention remains crucial but may be deferred in cases of profound systemic compromise.