A rare case of quadruple valve infective endocarditis of normal native valves - the advantage of TEE.

Quadruple valve infective endocarditis of apparently normal native valves is a relatively uncommon condition, reported particularly in the setting of intravenous drug use, structural heart disease and immunocompromised state, but its occurrence outside these settings is rare. Multiple valve endocarditis is caused by Staphylococcus aureus in the majority of cases. Although Enterococcus faecalis is a common cause of bacterial infective endocarditis overall, it is rarely reported to cause multiple valve involvement. The present case is one such rare report of a patient who had quadruple valve endocarditis of normal native valves, caused by E. faecalis. Compared to single valve endocarditis, multiple valve disease is associated more frequently with heart failure, perivalvular complications and need for heart surgery; hence, early recognition of the extent of disease and number of valves involved is crucial, as this in turn influences the management, risk of complications and outcomes. Transthoracic echocardiography is a widely used first-line tool in the imaging of infective endocarditis, but transesophageal echocardiography, which is more sensitive, should be used more frequently to assess the extent of involvement. Extensive valvular involvement alone does not preclude medical management, and surgical management should be considered only in those who do not respond to antimicrobials or in the case of hemodynamic compromise or mechanical complications.