Enterococcal Infective Endocarditis with Meningocerebral and Articular Involvement: An Unusual Diagnostic Presentation—A Case Report

Background: Enterococcus faecalis is the third leading cause of infective endocarditis (IE) and remains the predominant enterococcal species involved in this condition, particularly among older patients with multiple comorbidities and healthcare-associated exposure. Its diagnosis may be challenging because the disease often follows a subacute course and may initially present with atypical extracardiac manifestations. Case presentation: We report the case of a 76-year-old man admitted with a 5-day history of fever, chills, profuse diaphoresis, myalgia, abdominal pain, and progressive confusion. On admission, he was febrile, hypotensive, disoriented, and presented with neck stiffness, a grade IV aortic murmur, suprapubic tenderness, hepatomegaly, and hemorrhagic lesions of the left hand. Initial transthoracic echocardiography did not reveal valvular vegetations. Cerebrospinal fluid analysis showed inflammatory changes with marked granulocytic predominance, whereas the multiplex PCR panel for meningitis/encephalitis pathogens and conventional cerebrospinal fluid cultures remained negative. In contrast, all blood cultures yielded E. faecalis. Repeat cranial computed tomography demonstrated a focal parasagittal frontal lesion involving the rostrum and genu of the corpus callosum, consistent with septic embolic involvement. Transesophageal echocardiography performed on hospital day 5 confirmed aortic valve IE, showing vegetative lesions on all cusps, the largest measuring approximately 8 mm, and severe aortic regurgitation. The clinical course was further complicated by cardiac decompensation and acute inflammatory involvement of the left knee, with synovial fluid analysis demonstrating a neutrophil-predominant inflammatory effusion, although cultures remained sterile. The patient received ampicillin plus vancomycin, followed by ampicillin plus linezolid after vancomycin-associated renal impairment. Follow-up blood cultures became negative after 3 weeks of treatment, but persistent severe aortic valve involvement required referral for cardiac surgical evaluation. The patient was readmitted to the cardiology department and subsequently developed multi-organ system failure, resulting in death one week after discharge. Conclusions: This case highlights the diagnostic complexity of. E. faecalis IE when meningocerebral and osteoarticular manifestations dominate the initial presentation, emphasizing the importance of repeated blood cultures and early transesophageal echocardiography.