Case Presentation: This is a case of a 58-year-old male with history of urethral stricture s/p dilation who presented with progressive dyspnea, nonproductive cough and fever. Chest x-ray revealed bilateral diffuse opacification concerning for pneumonia, CTA showed no PE. The patient was initiated on levofloxacin for Pneumonia, heparin infusion for NSTEMI and was admitted to the ICU for further management. During his course in the ICU he became progressively tachypneic and was eventually intubated. Imaging at this stage showed ARDS. Bronchoscopy showed no significant secretions, BAL studies were unrevealing. He was noted to be continually hypotensive with increasing pressor requirements. Blood cultures at 48 hours, revealed only gram positive cocci, speciation remained pending. Patient’s diastolic blood pressure was noted to be low with a wide pulse pressure. Differentials at this point included ARDS secondary to Sepsis from Pneumonia, however blood cultures from admission identified Aerococcus Urinae at 72 hours. Mixed shock, both septic & cardiogenic were considered due to the wide pulse pressures. TTE done revealed no valvular vegetations, but TEE was significant for vegetation 2x 0.9cm over aortic valve leaflets, perforation of non-coronary, left coronary cusps a small aortic root abscess, eccentric aortic regurgitation jet, with mildly dilated aortic root. His hospital course was further complicated by worsening shock and kidney function necessitating CRRT, and non-resolving lactic acidosis. He was transferred to an outside facility for possible surgical evaluation of infectious endocarditis. Unfortunately he was deemed unstable for surgery, eventually transitioned to comfort measures only.

Discussion: Aerococcus Urinae is a rare gram positive cocci previously known to cause < 1% of UTI, but more recently has been associated with biofilm production and infective endocarditis. Less than 50 cases of IE by A. Urinae have been reported in literature, of which only few are described as invasive. Implicated risk factors for Aerococcus bacteremia are male gender, age> 65, and pre-existing urinary tract pathology. Studies show A. Urinae may resemble alpha-hemolytic streptococcus or enterococci at 24-48 hours. History of urethral instrumentation is a known risk factor, for colonization.This patient came in with hypoxia presumed to be from Pneumonia complicated by sepsis and ARDS but was found to have Aerococcus at 72 hours on blood cultures. Severe sepsis from A. Urinae leading to ARDS became the leading differential. Remote history of urethral instrumentation retrospectively is thought to possibly have led to colonization of the bacteria. Most A.Urinae respond to Penicillins, Aminoglycosides and Fluroquinolones. Our patient was being treated with levofloxacin but continued to worsen, Ceftriaxone was added after bacteria came to be known. It is noteworthy that septic shock had set in the interim it took to speciate blood cultures. This case is also an example of TTE being a less sensitive test to diagnose aortic valve vegetations.

Conclusions: We recommend a high index of suspicion for infective endocarditis from Aerococcus Urinae in cases of shock from alpha hemolytic gram positive cocci bacteremia. This is especially important in the setting of rapidly progressive shock. Risk for colonization after urethral instrumentation is noteworthy. TEE has more sensitivity to investigate aortic valvular vegetations. Early diagnosis and treatment is essential to prevent profound shock.