A 21 year old man, with a history of tissue aortic valve replacement for aortic regurgitation secondary to bicuspid aortic valve, and with good dental hygiene, presented with a four week history of malaise, nausea, anorexia, and fever. In the week preceding hospital admission, he started having abdominal pain.
Physical examination revealed pyrexia, tachycardia, one splinter haemorrhage, soft systolic murmur, a tender left hypochondrium with no rebound or guarding, and good bowel sounds. Initial investigations showed a raised white cell count of 20×109/l, C reactive protein of 300 mg/dl, normal renal function, and three sets of blood cultures which grew Streptococcus viridans. He had a transoesophageal echocardiogram which did not show vegetations but there were features suggestive, but not typical, of aortic root abscess. The patient was treated with benzyl penicillin and gentamicin.
In view of the abdominal pain, he had an abdominal x ray, which showed dilated small and large bowels. A computed tomographic (CT) scan of the abdomen showed splenic infarcts and renal emboli (upper and lower panels), in keeping with septic emboli.
The patient underwent aortic valve replacement the next day. An aortic root abscess was evident. He had an uncomplicated recovery from his surgery and his abdominal complications resolved, without any further intervention. He was discharged seven weeks after admission.