A diagnostic challenge: right-sided infective endocarditis presenting as isolated fatigue in a psychiatric patient

Infective endocarditis (IE) remains a diagnostic and therapeutic challenge due to its heterogeneous presentation and potential for severe embolic complications. Right-sided infective endocarditis (RSIE) accounts for only 5–10% of all IE cases, most commonly associated with intravenous drug use. Psychiatric comorbidities and language barriers may further delay diagnosis, as symptoms are often nonspecific and communication may be impaired. We report a rare case of right- and left-sided pneumococcal endocarditis in a patient with chronic schizophrenia, initially presenting with isolated asthenia, in whom diagnosis was delayed by neuropsychiatric and linguistic factors. A 48-year-old man from Guadeloupe, with a history of schizophrenia and poor treatment adherence, presented to the emergency department with history of afebrile asthenia and weight loss. Physical examination revealed confusion, dysarthria, and a mild systolic murmur, without overt heart failure. Laboratory tests showed inflammatory syndrome (CRP 170 mg/L, WBC 27 × 10⁹/L) and normocytic anemia (Hb 7.4 g/dL). Thoracoabdominal CT revealed bilateral proximal pulmonary embolism with septic emboli. Transthoracic echocardiography demonstrated a large vegetation (33 mm) on the tricuspid valve and a second lesion on the aortic valve, with a patent foramen ovale. Blood cultures grew Streptococcus pneumoniae. Brain MRI showed multiple ischemic lesions, while abdominal imaging identified a septic renal embolus. The diagnosis of dual right and left S. pneumoniae endocarditis with multiorgan embolic dissemination was retained. After antibiotherapy was transferred to a tertiary cardiac surgery center for urgent intervention. This case highlights the diagnostic complexity of RSIE, particularly in patients with psychiatric disorders and communication barriers, where non-specific symptoms such as fatigue may mask severe embolic disease. Early consideration of infective endocarditis in cases of unexplained sepsis, even in the absence of fever or classical cardiac findings, is crucial. In selected cases of atypical sepsis, echocardiography could represent a useful adjunct to the diagnostic approach, potentially limiting diagnostic delay in high-risk or vulnerable populations.