A silent sequel to Kshara Sutra: Enterococcus faecium–induced infective endocarditis in mitral valve prolapse

Background: Enterococcus faecium is an opportunistic Gram-positive organism that forms part of the normal gastrointestinal flora and is increasingly recognized as an important nosocomial pathogen. Although infective endocarditis caused by Enterococcus faecium is relatively uncommon, it is associated with significant morbidity due to antimicrobial resistance and prolonged bacteremia. Infective endocarditis following a Kshara Sutra procedure is an exceptionally rare clinical presentation, particularly in patients with underlying structural heart disease. Case
Description: A patient with mitral valve prolapse presented with prolonged fever, night sweats, cough, weight loss, and elevated inflammatory markers following a Kshara Sutra procedure. Blood cultures grew Enterococcus faecium, and echocardiography demonstrated vegetation on the mitral valve with severe mitral regurgitation, confirming the diagnosis of infective endocarditis. The patient was treated with prolonged intravenous antibiotic therapy, resulting in clinical improvement, and was discharged in stable condition. 
Case Assessment: The diagnosis was established based on positive blood cultures and echocardiographic evidence of mitral valve vegetation, consistent with infective endocarditis. The temporal association between the Kshara Sutra procedure and symptom onset suggested a possible procedural source of bacteremia in the presence of a predisposing valvular abnormality. 
Conclusion: This case highlights the rare occurrence of Enterococcus faecium infective endocarditis following a Kshara Sutra procedure in a patient with mitral valve prolapse. It emphasizes the importance of maintaining a high index of suspicion for infective endocarditis in patients with persistent fever after invasive procedures, particularly those with underlying valvular heart disease. Early diagnosis and appropriate prolonged antimicrobial therapy are essential to achieve favorable clinical outcomes.