A 64-year-old man with ulcerative colitis was admitted to hospital for 2 weeks of high temperature and tiredness. One month before admission he had undergone aortic valve replacement surgery (PERIMOUNT bioprosthesis, Edwards Lifesciences, United States). Infective endocarditis (IE) was suspected and large vegetation on aortic prosthesis valve was seen. In his fifth day of admission, he rapidly progressed to cardiogenic shock due to left-outflow tract obstruction (Fig. 1A), requiring emergent surgery. Blood cultures were negative. As soon as the explanted prosthetic valve culture showed Aspergillus flavus Voriconazole and Micafungin were initiated. Despite early surgery and antifungal therapy, he had an early relapse of IE. During this second episode, he developed multiple embolisms: right-common iliac artery thrombosis (Fig. 1B, red arrow), left femoral artery thrombosis (blue arrow), left popliteal artery thrombosis (green arrow), spondylodiscitis (Fig. 1C), and celiac trunk thrombosis (Fig. 1D). He also developed left parietal intracranial hemorrhage (Fig. 1E).

Fig. 1

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He underwent a third cardiac surgery (Aspergillus flavus was again isolated) and vascular intervention, but after a long hospitalization, he finally died.

This image depicts the clinical features of fungal endocarditis, a rare disease with poor prognosis, characterized by large bulky vegetations, recurrent embolisms, and periannular complications.

Our patient was immunocompromised and the first surgery was undertaken during the construction of a department annexed to the operating room, which was suggested as the portal of entry. Diagnosis can be challenging as most of the time blood cultures are negative or slow-growing. Treatment strategy must be aggressive, with medical and surgical combined approach. Authors received the patient's consent to publication.