A 39-year-old man with stable aortic regurgitation secondary to congenital bicuspid aortic valve was diagnosed with Streptococcus mitis infective endocarditis with low minimum inhibitory concentration to penicillin. Initial transoesophageal echocardiography demonstrated aortic root oedema with vegetations seen on the aortic valve. Despite improving clinical parameters on intravenous penicillin and gentamycin, a repeat transoesophageal echocardiogram 1 week later showed para-aortic valvular abscess, a fistula extending from the aortic root to the right atrium, and a vegetation on the tricuspid valve. This patient underwent urgent surgical repair of aortic valve.
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