Enterococcus faecalis Aortic Valve Endocarditis Masquerading As Urinary Tract Infection: Diagnostic Delay, Septic Embolic Strokes, and a Fatal Therapeutic Impasse.

We present a case involving a 67-year-old man with multiple comorbidities who initially experienced two weeks of gastrointestinal symptoms that were managed as acute gastroenteritis. He later returned to the emergency department with altered mental status following a fall. Initial evaluation showed leukocytosis, findings consistent with a urinary tract infection, and elevated cardiac biomarkers. Head computed tomography revealed a right frontal lobe hypodensity, while imaging of the chest, abdomen, and pelvis showed diffuse lymphadenopathy. Blood cultures identified vancomycin-susceptible Enterococcus faecalis, and urine cultures grew Escherichia coli, indicating two separate infections. Although transthoracic echocardiography was initially negative, transesophageal echocardiography (TEE) later confirmed aortic valve endocarditis with a perivalvular abscess and a possible left atrial appendage thrombus. The patient's course was complicated by multifocal embolic cerebral infarctions with hemorrhagic transformation, subarachnoid hemorrhage, new-onset atrial fibrillation, acute hypoxic respiratory failure due to volume overload, and acute kidney injury. He was considered a prohibitively high-risk surgical candidate because of recent cerebrovascular events and extensive comorbidities. After a prolonged hospitalization involving multiple facility transfers and multidisciplinary evaluation, the patient chose comfort measures and subsequently died. This case underscores the diagnostic challenges of infective endocarditis presenting with nonspecific symptoms, the value of TEE when clinical suspicion remains despite a negative transthoracic study, and the severe consequences of delayed diagnosis.