Septic embolization without visible vegetations: The challenges of image-negative endocarditis or severe disseminated bacteremia.

UNLABELLED: Infective endocarditis remains a life-threatening condition with high morbidity and mortality, particularly when caused by methicillin-sensitive Staphylococcus aureus. Early diagnosis is essential yet often challenging, especially when typical valvular vegetations are absent.We present the case of a 41-year-old man with methicillin-sensitive S. aureus bacteremia, complicated by retropharyngeal abscess, pyomyositis, empyema, and septic lung embolization. Multiple peripheral stigmata, including Osler nodes, Janeway lesions, and splinter hemorrhages fulfilled the modified Duke criteria for definite endocarditis, despite no imaging evidence of vegetations, in repeated echocardiograms, as well as fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography scan. Early antibiotic therapy and drainage of empyema and leg abscess led to a full recovery. This case illustrates the diagnostic limitations of imaging in native valve endocarditis, where small or mural vegetations may be overlooked. It underscores the critical role of clinical judgment in managing bacteremia with systemic involvement, ensuring timely and appropriate treatment despite negative imaging. LEARNING OBJECTIVE: Infective endocarditis may be present despite the absence of vegetations on echocardiography or positron emission tomography imaging. The diagnosis must integrate microbiological results and clinical findings, such as peripheral stigmata such as Osler nodes and Janeway lesions. This case emphasizes the limitations of imaging, the continued value of bedside examination, and the importance of applying the modified Duke criteria to ensure timely recognition and treatment of endocarditis.