Infective endocarditis presenting with myocardial infarction with non-obstructive coronary arteries

RATIONALE: Infective endocarditis (i.e.) results from the combined effects of multiple factors, such as frequent vascular access procedures and impaired immune system function, and is relatively common among patients with uremia undergoing long-term hemodialysis. Myocardial infarction with nonobstructive coronary arteries (MINOCA) may present as an atypical clinical presentation, especially in patients with multiple comorbidities. PATIENT CONCERNS: We report a rare case of a 52-year-old male who underwent regular hemodialysis using a tunneled-cuffed catheter and presented with persistent acute chest distress and pain for 4 hours. DIAGNOSES: Immediately after defecation, the patient developed persistent severe chest pain, shortness of breath, and profound sweating. ST-segment depression and T-wave alterations in the inferior leads (II, III, and aVF) on the initial ECG, together with elevated troponin I levels, raised suspicion of acute myocardial infarction (AMI). Emergency coronary angiography showed an irregular aortic valve, no significant stenosis of the left main coronary artery, 20-30% stenosis of the middle segment of the anterior descending artery, 30-40% stenosis of the circumflex artery, and no significant stenosis of the right coronary artery. Laboratory results revealed an increased percentage of white blood cells, neutrophils, and C-reactive proteins (CRP). Cardiac ultrasonography revealed hyperechogenicity of the aortic valve, suggesting the presence of vegetation. Considering the patient's history of uremia, long-term hemodialysis, and the absence of obstructive coronary arteries, MINOCA secondary to IE was suspected. INTERVENTIONS: Treatment with broad-spectrum antibiotics was initiated. Given the echocardiographic findings of massive and moderate aortic valve regurgitation, the patient underwent aortic valve replacement with cardiopulmonary bypass. OUTCOMES: The patient's inflammatory markers and white blood cells significantly decreased, serum troponin decreased, and ST-T changes in the ECG significantly recovered. After mechanical aortic valve replacement, the patient was discharged with anti-infection therapy, cardiac strengthening, blood purification, and nutritional support. LESSONS: The clinical presentation of infective endocarditis is atypical in patients undergoing dialysis, especially in the presence of other life-threatening conditions. Early multimodal imaging and multidisciplinary collaboration are essential for the timely diagnosis and management of MINOCA and IE.