Quadrivalvular Enterococcus faecalis Infective Endocarditis in a Patient With Complex Comorbidities

BACKGROUND: Panvalvular infective endocarditis (IE) involving all 4 cardiac valves is extremely rare, with a high mortality. Management is complex when surgical intervention is precluded by severe comorbidities. CASE SUMMARY: An 81-year-old woman with end-stage renal disease and metastatic bronchial carcinoma presented with Enterococcus faecalis bacteremia. Initial transthoracic echocardiography was unremarkable, but transesophageal echocardiography (TEE) revealed vegetations on all 4 valves with severe aortic and tricuspid regurgitation. Surgery was precluded by prohibitive risk. Despite targeted antibiotic therapy, she experienced progressive hemodynamic decline and expired after a transition to comfort care. DISCUSSION: This case highlights the indolent nature of E faecalis IE and the vital necessity of early TEE in high-risk patients. TAKE-HOME MESSAGES: Panvalvular IE carries an extremely poor prognosis without surgery. Early TEE is essential for diagnosis. When extensive mechanical valvular destruction precludes surgical intervention, medical management alone rarely prevents fatal hemodynamic failure, necessitating timely goals-of-care discussions.