Case Presentation:

A 59‐year‐old man presented with a 3‐month history of a dry cough. He denied smoking. On further questioning, he noted a 9‐month history of dyspnea that began after an appendectomy. During that hospital course, a urinary catheter had been placed secondary to urinary retention and hypospadias. Prior to surgery, he ran 5K races.


On presentation, he was tremulous and tachypnea His vital signs were otherwise normal, A 6‐cm jugular venous distension was observed, and a blowing diastolic murmur. Spider angiomas were present on his chest. His lungs were clear to auscultation, and he had no hepatomegaly or neurologic deficits. The chest x‐ray showed bilateral calcified granulomas; a chest CT angiogram demonstrated mild cardiomegaly with pulmonary edema. It did not demonstrate a pulmonary embolism. A subsequent urinary histoplasma antigen was negative. WBC was 25.1. Although the initial EKG did not exhibit any ST changes, the initial cardiac enzymes included an elevated troponin of 1.66. TTE was performed revealing a mobile aortic valve vegetation, severe aortic regurgitation, and grade lll/IV diastolic dysfunction. Closer inspection of valvular structures with TEE revealed a tricuspid aortic valve with 3 vegetations. When urine and blood cultures revealed E. faecalis, his empiric antibiotic regimen was changed from piperacillinllazobactam and vancomycin to piperacillin/lazobactam and gentamicin. He successfully underwent bovine aortic valve replacement. Endocarditis is common. The hospitaiist must be aware that the presentation of subacute bacterial endocarditis is very much unlike that of the more commonly encountered acute variety. Acute bacterial endocarditis, as is commonly seen in patients who use intravenous drugs, presents with a sudden onset of fever, malaise, and dyspnea. In subacute endocarditis, a pernicious fatigue, malaise, and nonspecific symptoms such as cough may be the only presenting findings. Our patient's cough eclipsed his more serious condition of enterococcal infective endocarditis (IE). As reported by a 15‐year retrospective study of 212 patients with subacute endocarditis, cough and dyspnea are common symptoms (45% and 50%). His aortic enterococcal endocarditis resulted in severe aortic insufficiency, and although his systolic function was preserved (LVEF > 55%), he consequently developed diastolic congestive heart failure. His cough was most likely secondary to the congestive heart failure, causing both interstitial and peribronchial edema.


Enterococcal IE risk factors indude gastrointestinal and urogenital procedures. Our patient had both, induding an appendectomy and a complicated urinary catheter placement due to hypospadias. As such, this case illustrates an important patient safety consideration, emphasizing the importance of judicious and infrequent use of urinary catheters, as prolonged catheterization results in an increase in systemic infections such as endocarditis.

Author Disclosure:

K. Wang, none.