Background: Infective endocarditis (IE) is a challenging disease to diagnose often presenting with heterogeneous features. Blood cultures are the gold standard for diagnosing endocarditis, but it is important to know that up to 20 % of cases of infective endocarditis have negative blood cultures. Leukocytoclastic vasculitis (LCV) is a small vessel vasculitis and is idiopathic in 50% of cases. LCV is a rare but possible presentation of Infective endocarditis. Hence IE should be part of the differential diagnosis when LCV is diagnosed. Case summary: A 53-year-old male patient presenting right lower extremity pain and vesiculobullous lesions over bilateral upper and lower extremities. He is diagnosed with severe peripheral arterial disease (PAD) and leukocytoclastic vasculitis (LCV). For leukocytoclastic vasculitis, a causative factor could not be determined, hence, the patient was diagnosed with idiopathic LCV and was started on IV steroids. Simultaneously, the patient was determined to need bilateral AKAs for severe PAD. However, a preoperative transthoracic TTE) revealed a large vegetation on the mitral valve. Transesophageal echo (TEE) confirmed the presence of a large 2 cm X 1cm mass on the atrial aspect of the posterior leaflet The patient was presumptively diagnosed with culture negative endocarditis and empiric treatment with IV Vancomycin and IV cefepime was started. Cardiothoracic surgery was consulted for possible surgical removal of the vegetation, but the patient was deemed very high risk for mitral valve replacement. Consequently, the patient was treated with long term Antibiotics. Learning Points: Negative blood cultures increase the mortality rate in IE, a potentially lethal disease process. Adding a rare presentation of leukocytoclastic vasculitis to this mixture creates an even more challenging clinical picture. In culture-negative acute native valve endocarditis, empiric dual therapy with Vancomycin and cefepime for six weeks is appropriate as it covers organisms such as S. aureus, beta-hemolytic streptococci, and aerobic Gram-negative bacilli. Also, serologies for Coxiella Burnetii, Bartonella spp., brucella, legionella, and mycoplasma may be tested. Classical lesions seen in IE include Osler's nodes and Janeway lesions that histologically show septic emboli with inflammatory reactions. It is important to remember that patients presenting with LCV have also been diagnosed with infective endocarditis. Treating a patient with steroids or immunosuppressives (management of idiopathic LCV) can be detrimental to the treatment of an already highly morbid condition such as endocarditis. Therefore, it is important to keep an infectious cause such as IE in one's differential diagnosis while managing vasculitis.