A patient with aortic annular rupture secondary to blood culture-negative endocarditis: A case report

We report a rare case of aortic valve annular rupture secondary to culture-negative infective endocarditis. This report aims to summarize the diagnostic challenges, imaging-based differentiation, and microbiological strategies, serving as a reference for similar clinical scenarios. The patient presented with progressively worsening palpitations and chest tightness. Initial transthoracic echocardiography (TTE) suggested a unicuspid aortic valve, but subsequent transesophageal echocardiography (TEE) revealed an aortic valve annular rupture with severe regurgitation. The patient exhibited signs of infection, but both blood cultures and sputum bacteriology tests were negative. Surgical exploration revealed infective changes in the valve annulus; combined with valve pathology and second-generation gene sequencing results, the diagnosis of culture-negative infective endocarditis was confirmed according to the 2023 Duke-ISCVID (Duke-International Society of Cardiovascular Infectious Diseases) criteria. This case posed diagnostic challenges due to the transthoracic echocardiographic appearance mimicking a unicuspid aortic valve and the negative routine microbiological tests. It underscores the importance of promptly performing transesophageal echocardiography when encountering suspected rare valvular abnormalities. For suspected infective endocarditis (IE) with negative routine microbiological tests, early tissue molecular sequencing should be performed to clarify the pathogen.