Relapsing Enterococcus Faecalis Endocarditis in a Patient with Severe Aortic Stenosis and Heart Failure: Clinical Course and Management

Abstract

Background: Infective endocarditis caused by Enterococcus faecalis remains a challenging clinical entity, particularly in patients with pre-existing valvular heart disease and reduced left ventricular ejection fraction. Relapse after apparently adequate antimicrobial therapy poses significant diagnostic and therapeutic dilemmas.
Case Summary: A 51-year-old male with severe aortic valve stenosis and regurgitation, atrial fibrillation, and heart failure with reduced ejection fraction (LVEF 25%) presented with dyspnoea and night sweats. Following coronary angiography, the patient developed sepsis. Blood cultures revealed Enterococcus faecalis, and echocardiography demonstrated an aortic root abscess. Initial treatment with vancomycin and ceftriaxone was modified to teicoplanin due to nephrotoxicity. After six weeks of therapy, clinical improvement and recovery of LVEF to 45% were observed. Two months later, the patient experienced relapse with recurrent E. faecalis bacteraemia and worsening renal function. Given the life-threatening septic state, vancomycin-based therapy was reintroduced despite nephrotoxicity. After successful infection control, transcatheter aortic valve implantation (TAVI) was performed with favourable outcome.
Discussion: This case highlights the risk of relapsing enterococcal endocarditis after invasive procedures in patients with structural heart disease. It underscores the importance of prolonged combination antimicrobial therapy, careful renal monitoring, and timely valve intervention after infection eradication.