Right ventricular thrombus: an unusual manifestation of Behçet's disease

Case Report: A Mysterious Giant Thrombus in the Right Atrium in a Patient With Dilated Cardiomyopathy

An isolated right atrial thrombus is a life-threatening entity that is extremely rare in patients with dilated cardiomyopathy (DCM), which is characterized by a reduced left ventricular function and consequent left ventricular thrombosis. Here, we present the case of a mysterious isolated giant right atrial thrombus in a male patient with DCM. The presence of deep vein thrombosis prompted us to investigate for other underlying diseases for his right atrial thrombus. Interestingly, the elevation of two tumor markers indicated the likelihood of cancer-associated thrombosis. Further, the computed tomography demonstrated a spiculated mass in the lower right lung that was confirmed by an endobronchial biopsy as lung squamous cell carcinoma. Consequently, the giant thrombus in the right atrium should be attributed principally to lung squamous cell carcinoma on the background of DCM. After 3 weeks of enoxaparin, the echocardiogram indicated partial resolution of the thrombus. However, the patient suffered sudden death due to pulmonary embolism.

Cardiac manifestations in Behcet's disease

Behcet's disease (BD) is a chronic inflammatory disorder, with vasculitis underlying the pathophysiology of its multisystemic effects. Venous pathology and thrombotic complications are hallmarks of BD. However, it has been increasingly recognised that cardiac involvement and arterial complications are also important aspects of the course of the disease. Cardiac lesions include pericarditis, endocarditis, intracardiac thrombosis, myocardial infarction, endomyocardial fibrosis, and myocardial aneurysm. Treatment of cardiovascular involvement in BD is largely empirical, and is aimed towards suppressing the vasculitis. The most challenging aspect seems to be the treatment of arterial aneurysms and thromboses due to the associated risk of bleeding. When the prognosis of cardiac involvement in BD is not good, recovery can be achieved through oral anticoagulation, immunosuppressive therapy, and colchicine use. In this review, we summarise the cardiovascular involvement, different manifestations, and treatment of BD.

[Cardiovascular involvement in Behçet's disease]

Vascular involvement is a common complication of Behçet's disease (BD) and affects up to 40% of BD patients. These complications worsen the prognosis of BD. The concept of vasculo-Behçet has been adopted for cases in which vascular complications dominate the clinical features. Vascular manifestations affect particularly young men, during the first years following onset of the disease. Venous complications are the most frequent vascular complications, affecting 14 to 40% of BD patients. Superficial and deep lower limb thrombosis is the most frequent venous complications but one third of venous thrombosis concern large vessels (such as cerebral venous thrombosis, pulmonary embolism, and inferior or superior vena cava, etc.). Budd-Chiari syndrome is the worst prognostic factor increasing mortality by 9 times. Arterial complications (2 to 17% of BD patients) include aneurysms and occlusions/stenosis. Main locations of arterial lesions are aortic (abdominal and thoracic), femoral, pulmonary and iliac arteries. Aneurysms are the most severe arterial complications, particularly pulmonary aneurysms associated with a high risk of massive bleeding. Cardiac complications (up to 6% of BD patients) include pericarditis, endocardial lesions (aortic regurgitation and less often mitral insufficiency), myocardial lesions (myocardial infarction, myocarditis and endomyocardial fibrosis) and intracardiac thrombosis (right ventricle and atrium). Coronary lesions complicated to myocardial infarction are the most severe cardiac complications. Treatment is based on corticosteroids and immunosuppressive drugs. The use of anticoagulation in venous thrombosis is still controversial.

Behçet's Disease and Intracardiac Thrombosis: A Report of Three Cases

We present three patients with Behçet's disease associated with intracardiac thrombus and pulmonary vascular involvement. One of these patients had also Budd-Chiari syndrome. All patients were treated with corticosteroid plus monthly intravenous cyclophosphamide as first line treatment and with no recurrences. Immunosuppressive therapy was successful in the treatment of intracardiac thrombus and also in the regression of pulmonary vascular thromboses in these patients. Intracardiac thrombus in Behçet's disease is rarely seen. Behçet's disease should be remembered in the differential diagnosis of the patients with intracardiac mass, especially in patients from the Mediterranean and Middle East populations.

Cardiovascular involvement in Behçet's disease

Behçet's disease is a chronic relapsing systemic vasculitis that can involve almost every organ and systems in the body with extremely different diverse manifestations. Cardiovascular involvement is one of these manifestations, the involvement of which might present in various patterns in itself. Cardiovascular involvement is relatively uncommon in Behçet's disease; however, Behçet's disease is relatively rather common in certain parts of the world. Therefore, especially in these locations recognizing such miscellaneous presentations are of critical importance, since cardiovascular involvements exceed other presentation in mortality and morbidity rates. Based on these facts, in this review, we summarized the cardiovascular involvements and its different manifestations in Behçet's disease.

Pseudotumeur cardiaque révélant une maladie de Behçet

INTRODUCTION

Cardiac thrombosis is a rare complication of Behçet's disease (BD), which may present as a cardiac tumor. Its discovery precedes, in half of the cases, the diagnosis of BD. The high mortality may be associated to postsurgical complications and/or an associated involvement of pulmonary arteries.

CASE REPORT

We present the case of a 31 years old Caucasian French woman, with a history of venous thromboembolic disease, who had surgery after the discovery of a right ventricle tumor. That was an organised thrombus with endomyocardial fibrosis and a diagnosis of Behçet's disease was made after the surgery. The outcome was favourable under medical treatment associating corticosteroids, colchicine and antivitamin K (AVK), without relapse four years later.

CONCLUSION

The discovery of an intracardiac mass in a young patient must evoke the diagnosis of cardiac thrombus and Behçet's disease, even in the absence of predisposing ethnic or geographic factor.

Right ventricular outflow tract thrombus in a case of Behçet’s disease

Behcet's disease is known as a chronic systemic vasculitic syndrome, the hallmark of which is recurrent oral aphthous and genital ulcerations and uveitis. Vascular involvement, mainly thrombosis, reportedly affects as many as one-third of patients. Cardiac involvement, however, is very rare. We present in this report a young female patient developing right ventricular thrombus while being treated medically.

Cardiac complications in Behçet's disease

Behçet's disease (BD) is a multisystem disease of unknown aetiology characterized by chronic relapsing oro-genital ulcers, uveitis, and systemic involvement including articular, gastrointestinal, cardiopulmonary, neurologic and vascular pathology. Vascular involvement is observed in 30% of cases. Although the pathogenic mechanisms underlying the thrombotic disposition in BD are not well known, prothrombin (PT) gene mutations may be one factor that contributes to the development of vascular involvement in this disorder. We report a case of BD with a PT gene mutation, presenting with cardiovascular involvement.

Behçet's disease with a large intracardiac thrombus: a case report

Behçet's disease is recognised as a chronic multisystem disorder with vasculitis as its underlying pathological process. Cardiac involvement is rare and often associated with poor prognosis. A case of a 33 year old man with Behçet's disease, presenting with a large right ventricle and right atrial thrombus, is reported. Two dimensional (cross sectional), colour Doppler, and transoesophageal echocardiography, angiography, computed tomography, and magnetic resonance imaging were used to diagnose the disease. With cyclophosphamide and dexamethasone treatment, the cardiac lesions progressively resolved.

Cardiac thrombosis in a patient with Behçet's disease: two years follow-up

A 28-year-old man with Behçet's disease was presented with cardiac symptoms in addition to previous complaints of oral and genital ulcers. A diagnosis of thrombosis was made and patient began to receive anticoagulant and immunosuppressive therapy and was followed by echocardiographic examination. Despite medical therapy, thrombosis recurred. Surgical excision was performed and histological findings were consistent with organizing thrombus. Nature of cardiac involvement and review of literature on cardiac thrombosis in Behçet's disease was discussed.

Intracardiac thrombus in Behçet's disease: a systematic review

BACKGROUND

Intracardiac thrombus formation is a rare but serious complication of Behçet's disease. We aimed to review the clinical and pathologic correlates of cardiac thrombus formation in the context of Behçet's disease.

METHODS AND RESULTS

A comprehensive search of the medical literature was conducted using MEDLINE including bibliographies of all selected articles. Although the disease has a unique geographic distribution, being most common in the population of the ancient Silk Route, cases complicated by intracardiac thrombus have mostly originated from the Mediterranean basin and the Middle East. Young men appear to be most at risk, with the right heart the most frequent site of involvement. The first symptoms and signs of the disease frequently precede systemic organ manifestations. In those cases in which intracardiac thrombus occurs, it is apparent in more than half of cases on first recognition of the disease.

CONCLUSION

A diagnosis of Behçet's disease should be considered if a patient presents with a mass in the right-sided cardiac chambers, even in the absence of the characteristic clinical features of the condition. This is particularly applicable if the patient is a young man from the Mediterranean basin or the Middle East.

A fatal case of Behçet's disease associated with multiple cardiovascular lesions

Behçet's disease is recognised as a chronic multisystem disorder with vasculitis as its underlying pathological process. Cardiac involvement is rare and often associated with poor prognosis. A large right atrial thrombus, pulmonary aneurysms and aortic pseudoaneurysm that developed 17 years after surgery for bilateral renal artery stenosis is presented in a 26-year-old Behçet's disease patient. He was admitted to the hospital with fever of unknown origin associated with chest pain, dyspnea, cough, haemoptysis and pulmonary opacity in chest X-ray. Initial pulmonary CT demonstrated small subpleural infiltrates bilaterally, one of which was round and suspected as being metastatic. Examination of open lung biopsy demonstrated haemorrhagic infarct surrounded by some occluded pulmonary arteries. Subsequent CT showed pulmonary aneurysms compatible with Behçet's disease. Echocardiography demonstrated a large pedunculated mass in the right atrium. Injection of urographin showed a right atrial mass and a large right pulmonary artery aneurysm. The atrial mass was completely excised during open heart surgery and was identified as being an organising thrombus. Eight weeks later while taking prednisone, he was readmitted because of an infected mid sternal wound. CT showed slight separation of the stemum, retrosternal fluid, pulmonary arteries aneurysm and ascending aorta aneurysm. The next day, the patient died from massive bleeding from his ruptured ascending aortic pseudoaneurysm. Bizarre presentation of arterial and venous thromboses or arterial aneurysm formation, particularly in young patients, should suggest Behçet's disease.