A 44-year-old man with a bioprosthetic aortic valve suffered destructive endocarditis with severe embolic disease due to Bartonella henselae infection. Multilocus sequence typing was successfully performed with crude preparations of operative tissue as templates, and the infecting organism was determined to be typical of the Houston clonal group, although it was never cultured from blood or tissue. This is the first report of B. henselae infection in the South Pacific, and it reminds one that B. henselae is a cause of potentially lethal culturenegative endocarditis which may respond poorly to conventional empirical therapy. Nothing is known of the epidemiology of the infection in this region, but it is likely to be common and to contain representatives of both major clonal complexes. This study emphasizes the ease with which multilocus sequence typing can be used directly with tissue, which is important because of suggestions of strain-dependent clinical outcomes. CASE REPORTA 44-year-old New Caledonia man presented to his local hospital from his home in urban Noumea with the sudden onset of right-sided hemiparesis and aphasia. The patient had undergone bioprosthetic aortic valve replacement for severe aortic regurgitation from a congenital bicuspid valve 2 years earlier without complications or any suggestion of perioperative infection. He was on no immunosuppressive therapy and was not diabetic. His only other medical history was that of essential hypertension, and he recalled no specific history of an inflammatory nodule or marked regional adenopathy or any specific exposure to a cat scratch or bite. His symptoms completely resolved, but he presented again 5 months later with a similar neurological deficit associated with headaches and vomiting. A cerebral computerized tomography scan demonstrated two distinct lesions consistent with embolic infarcts. Transesophageal echocardiography in Noumea failed to detect evidence of endocarditis; however, empirical treatment with vancomycin was commenced after several blood cultures failed to disclose a causative agent.For neurosurgical assessment, the patient was transferred to Australia, where computerized tomography of the chest and abdomen demonstrated cardiomegaly, a left pleural effusion, and multiple splenic infarcts. Magnetic resonance imaging revealed bilateral cerebral infarcts of various ages associated with localized Wallerian degeneration and a small infarct involving the thoracic cord. Since an occipital lesion had been complicated by limited hemorrhage, a cerebral angiogram which excluded mycotic aneurysms was performed. The neurosurgical opinion at this time was that these lesions were most consistent with embolic phenomena, implicating the prosthetic valve. All antibiotic therapy was ceased for 48 h on the arrival of the patient in Australia, and three cultures of blood taken during this time were again reported to be negative. Investigations at this time also revealed moderate renal impairment with nephrotic-range (5 g/day) proteinuria, which was attri...

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