INVESTIGATION
The patient’s blood work showed leukocytosis, normocytic anemia, elevated creatinine, and the presence of RBCs, nitrites, and proteins on urinalysis. A chest X-ray ruled out any lung pathologies. A CT chest (Figure 2B) , abdomen and pelvis ruled out renal or pulmonary pathologies and was started on Ceftriaxone 1g IV. Initial blood culture revealed gram-positive cocci for which Piperacillin-Tazobactam 3.375g q6h IV (Pip-Tazo) was added to the treatment. Subsequently, the blood cultures showed Methicillin Sensitive Staph Aureus (MSSA) bacteremia and therapy was changed to Vancomycin 2g IV loading dose followed by 1250mg IV q12h and Cefazolin 2g IVq8h. The patient had a transthoracic echocardiogram (TTE) which demonstrated moderate aortic regurgitation and severe aortic stenosis with bi-atrial enlargement. However, the transesophageal echocardiography (TEE) showed a well loculated large area of echo-dense material around the aortic valve consistent with a peri-aortic abscess (Figure 2A) with no evidence of endocarditis. Cardiac catheterization was normal.