Four-Valve Endocarditis Initially Presenting With Peripheral Embolism

Although infective endocarditis is rare (3–10/100 000/year), it increasingly affects older patients with damaged or prosthetic heart valves; men are twice as likely to be affected as women. A 66-year-old male patient presented with pain in his right hand. Clinically, the radial artery pulse was not palpable, and duplex ultrasound revealed a thrombotic occlusion of the axillary artery. Laboratory tests showed a marked inflammatory response (leukocytosis, CRP of 182 mg/L). Following emergency thrombectomy (Figure 1), empiric antibiotic therapy (ampicillin, flucloxacillin, and gentamicin) was initiated. Transesophageal echocardiography (Figure 2) showed vegetations (irregularly shaped, mobile masses) on the mitral, aortic, tricuspid, and pulmonary valves. A diagnosis of four-valve infective endocarditis was made. Blood cultures remained sterile, indicating culture-negative endocarditis. Over the course of follow-up, the vegetations regressed without relevant valvular dysfunction. Follow-up at 6 months showed a stable clinical condition. In cases of peripheral embolism accompanied by a systemic inflammatory response, endocarditis should be considered promptly. Causes of culture-negative forms include prophylactic antibiotic treatment, difficult-to-detect pathogens (Coxiella, Bartonella, Tropheryma), and autoimmune disorders (Libman–Sacks endocarditis).

Figure 1

Thrombus removed intraoperatively from the axillary artery in the setting of infective endocarditis. The macroscopic specimen was a fresh, spindle-shaped thrombus measuring 3 cm in length, removed by open thrombectomy.

Figure 2

Transesophageal echocardiography showing hypoechoic, mobile structures on the mitral (right arrow) and tricuspid (left arrow) valves, consistent with vegetations in the setting of infective endocarditis.

Dr. med Matthäus Zerdzitzki, Abteilung für Gefäßchirurgie Barmherzige Brüder, Klinikum St. Elisabeth, Straubing, [e-mail]

Dr. med Jan Becher,II. Medizinische Klinik – Innere Medizin, Kardiologie, Konservative Intensivmedizin, Angiologie Barmherzige Brüder Klinikum St. Elisabeth, Straubing

Conflict of interest statement: The authors state that no conflict of interest exists.

Translated from the original German by Christine Rye.

Cite this as: Zerdzitzki M, Becher J: Four-valve endocarditis initially presenting with peripheral embolism. Dtsch Arztebl Int 2026; 123: 145. DOI: 10.3238/arztebl.m2025.0195