On August 3, 2006, a 53-year-old man with penicillin allergy presented with afebrile blood-culture-negative endocarditis (BCNE). He lived in an urban area near Marseille and had never travelled abroad. He did not report any specific food allergies. 4 months earlier, he had had a mitral valve replacement with a bioprosthetic valve (porcine Hancok II, Medtronic, Minneapolis, USA). Trans-oesophageal echocardiography identified vegetation on the bioprosthesis. Although blood cultures and serological test results were negative, empirical anti-staphylococcal therapy was started. The vegetation increased in size and caused valvular obstruction, necessitating a replacement with the same type of Hancok II valye. Our patient experienced two further relapses of afebrile BCNE necessitating mitral valve replacements, with Hancok II bioprostheses, in October and December, 2006. In June, 2007, he had a third relapse and died. Each removed valve showed inflammatory infiltrates and a vegetation, which led to diagnoses of endocarditis. At each episode, we tested blood samples and the removed valves using a comprehensive diagnostic procedure previously reported to identify the aetiology of BCNE.1 In each episode, all test results were negative.
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