Granulicatella elegans endocarditis: a diagnostic and therapeutic challenge

A 63-year-old man with a history of non-ischaemic cardiomyopathy presented with acute worsening of heart failure and septic shock. Echocardiogram revealed a large aortic valve vegetation with new onset severe aortic incompetence. Blood cultures grew Granulicatella elegans, for which antimicrobial sensitivities could not be carried out in our lab. Despite antibiotic therapy and aggressive care, the patient's clinical condition worsened and he died. G. elegans, previously grouped under nutrient variant streptococci (NVS), is an extremely rare cause for bacterial infective endocarditis (IE). Unlike with the Viridans group, IE caused by NVS has a very poor outcome and higher mortality rate. The difficulty in isolation of the bacteria in culture, inability to reliably measure antibiotic susceptibility in vitro, frequent treatment failure and complications such as multivalvular involvement, make this an extremely challenging infection to treat. Early detection of the organism, appropriate antibiotics and early surgical management when indicated, are key to management.