Bacterial Culture-Negative Acute Infective Endocarditis With Vegetation in Native Bicuspid Aortic Valve

A 51-year-old male with a past medical history of bicuspid aortic valve, hypertension, and anterior cerebral artery stroke of unclear etiology three months earlier, presented to the Emergency Department with progressive shortness of breath, hemoptysis, and night sweats. The patient's echocardiogram revealed a mobile mass greater than 1.0 cm in diameter on the bicuspid aortic valve, which was not present on the echocardiogram three months prior, during his stroke workup. Per modified Duke's criteria, this patient was found to have 'definite' infective endocarditis despite persistently negative blood cultures. The patient underwent urgent surgical aortic valve replacement and a ventricular septal defect was noted that was not seen on prior imaging. The patient was discharged on intravenous antibiotics and warfarin. The patient was able to return to his normal functional status weeks after surgery, and is continuing to exercise without limitation. This case provides an example of patients with bicuspid aortic valves having an increased propensity for developing infective endocarditis. While also highlighting the interesting intra-operative images and presentation of acute culture-negative endocarditis with vegetation, and the subsequent repair, treatment, and recovery.