1
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Rua CR, Laranjeira MR, Dionisio AC, Mendes MA, Martins LR. Unveiling Lung Adenocarcinoma: Non-bacterial Thrombotic Endocarditis as the Debut Sign. Cureus 2023; 15:e45271. [PMID: 37846253 PMCID: PMC10576842 DOI: 10.7759/cureus.45271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/18/2023] Open
Abstract
Non-bacterial thrombotic endocarditis (NBTE) involves the deposition of fibrin and platelets on heart valves, frequently leading to systemic embolism. The association between NBTE and cancer demands thorough investigation in cases lacking an evident cause. This case report elucidates the clinical course of a nonsmoking woman in her sixties with NBTE linked to pulmonary adenocarcinoma. The patient, who had a history of multiple sclerosis (MS) and was receiving dimethyl fumarate treatment, presented to the emergency department with stroke-like symptoms. Diagnostic challenges arose due to preexisting motor sensory impairment from MS. Initial evaluations revealed hypocapnia and elevated inflammatory markers. Blood cultures were obtained twice, and imaging confirmed pneumonia, left pleural effusion, and chronic pulmonary embolism while excluding acute vascular events or intracranial hemorrhage. The first transthoracic echocardiogram (TTE) indicated no cardiac abnormalities. Treatment encompassed parenteral antibiotics, systemic anticoagulation, and admission to medical floors. Although the initial treatment yielded a positive clinical response, subsequent complications emerged. On the tenth day, the patient required additional interventions, including broad-spectrum antibiotics and supplemental oxygen. A follow-up chest X-ray revealed persistent pneumonia and pleural effusion, and blood cultures upon admission returned negative. A subsequent head MRI confirmed an embolic stroke and displayed evidence of MS progression. Around the twentieth day, empirical treatment for infective endocarditis was initiated, and an 8 mm vegetation on the aortic valve was identified via transesophageal echocardiography (TOE). Acute pulmonary edema prompted a transfer to the intermediate care unit. Further investigations, including left thoracocentesis and CT, unveiled exudate and metastatic lesions in the liver, ilium, and kidney. Unfortunately, on the twenty-fifth day, the patient experienced acute myocardial infarction, right leg ischemia, disseminated intravascular coagulation, and shock. Pleural fluid analysis revealed malignant cells suggestive of lung adenocarcinoma. This case underscores the pivotal role of timely NBTE recognition and the search for malignancy when workup for infective endocarditis and autoimmune panels is negative. Moreover, it emphasizes the significance of vigilant monitoring, particularly in immunocompromised individuals or those with preexisting neurological deficits, especially when new neurological symptoms manifest. These insights significantly contribute to the comprehension of NBTE management and its implications for analogous patient cohorts.
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Affiliation(s)
- Catarina R Rua
- Rheumatology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Mariana R Laranjeira
- Internal Medicine, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Ana C Dionisio
- Internal Medicine, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Maria A Mendes
- Allergy and Immunology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Lourenco R Martins
- Radiology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
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2
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Vattikonda KS, Peterson CJ, Ayzenbart VI, Rutherford MS. Nonbacterial Thrombotic Endocarditis With Embolic Phenomena Diagnosed by Transesophageal Echocardiogram. Cureus 2023; 15:e45686. [PMID: 37868389 PMCID: PMC10590079 DOI: 10.7759/cureus.45686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 10/24/2023] Open
Abstract
Nonbacterial thrombotic endocarditis (NBTE) is a valvular disorder commonly associated with malignancy and connective tissue diseases. While the disorder is often discovered during autopsy, it is sometimes diagnosed in patients who present with systemic embolization. Here, we discuss the case of a 52-year-old female, with connective tissue disease and malignancy, who presented with symptoms of systemic embolization and was diagnosed with NBTE by transesophageal echocardiogram (TEE). This case highlights the utility of TEE in diagnosing NBTE and its influence in guiding the subsequent management of patients.
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Affiliation(s)
| | | | - Vira I Ayzenbart
- Cardiology, Virginia Tech Carilion School of Medicine, Roanoke, USA
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3
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Santiago LE, Kujundzic W, Wong S, Swaminath S, Aneja P. An Unusual Case of Nonbacterial Thrombotic Endocarditis Attributable to Malignancy. Cureus 2023; 15:e44734. [PMID: 37809183 PMCID: PMC10553845 DOI: 10.7759/cureus.44734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Nonbacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, is a condition characterized by the deposition of thrombi and fibrin on normal or degenerated cardiac valves in the absence of microorganisms. We report a case of a 60-year-old male with nonbacterial thrombotic endocarditis found on transesophageal echocardiogram (TEE) after a normal TEE just one month prior. Our patient presented with abdominal pain associated with poor appetite and unintentional 20-pound weight loss for one month. Chest computed tomography revealed the presence of a mass-like opacification in the right lung middle lobe with moderate pericardial effusions. A biopsy of the mass confirmed malignancy consistent with lung primary adenocarcinoma. Subsequently, during hospitalization, the patient developed left lower extremity pain. Arterial ultrasound showed occlusion of the distal left popliteal artery for which he underwent thrombectomy of the left superficial femoral artery, balloon angioplasty of the left posterior tibial artery, and left popliteal artery. Repeat TEE during current hospitalization revealed a large 2 cm vegetation on the noncoronary cusp of the aortic valve. Studies for infective endocarditis were unremarkable. Subsequently, he was treated with aortic valve replacement and anticoagulation. After discharge, he returned with bilateral occipital infarcts four days later and expired.
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Affiliation(s)
- Luis E Santiago
- Internal Medicine, Hospital Corporation of America (HCA) Florida Westside Hospital, Plantation, USA
| | - Winy Kujundzic
- Internal Medicine, Hospital Corporation of America (HCA) Florida Westside Hospital, Plantation, USA
| | - Stephanie Wong
- Internal Medicine, Hospital Corporation of America (HCA) Florida Westside Hospital, Plantation, USA
| | - Samyukta Swaminath
- Public Health, Emory University, Atlanta, USA
- Osteopathic Medicine, Nova Southeastern University, Davie, USA
| | - Pallavi Aneja
- Internal Medicine, Hospital Corporation of America (HCA) Florida Westside Hospital, Plantation, USA
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4
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Akiki E, Ahmad A, El-Am EA, Casanegra AI, Klarich KW, Kurmann R. Case report: New is not always better: treatment of non-bacterial thrombotic endocarditis. Front Cardiovasc Med 2023; 10:1208190. [PMID: 37502185 PMCID: PMC10369060 DOI: 10.3389/fcvm.2023.1208190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
An elderly female with metastatic adenocarcinoma of the lung and atrial fibrillation presented with multiple embolic strokes while on anticoagulation with Apixaban. After further investigation, a TEE showed lesions of non-bacterial thrombotic endocarditis on the mitral valve. A decision to switch the patient to LMWH for anticoagulation was then made and a follow-up TEE showed resolution of the NBTE. In this abstract, we show that heparin should remain as the anticoagulation agent of choice in the setting of NBTE associated with malignancy.
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Affiliation(s)
- Elias Akiki
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Ali Ahmad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
- Department of Internal Medicine, Saint Louis University School of Medicine, Saint Louis, MO, United States
| | - Edward A. El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Ana I. Casanegra
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Kyle W. Klarich
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Reto Kurmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
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5
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Charles K, Abraham A, Bassi R, Elsadek R, Cockey G. A Rare Case of Bartonella henselae Infective Endocarditis Causing an Embolic Cerebrovascular Accident. Cureus 2023; 15:e41364. [PMID: 37546133 PMCID: PMC10399704 DOI: 10.7759/cureus.41364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2023] [Indexed: 08/08/2023] Open
Abstract
Bartonella is a facultative intracellular Gram-negative aerobic rod that is an important cause of culture-negative endocarditis that only accounts for 3% of all infective endocarditis (IE) cases. Throughout the literature, there have been very few documented cases of an embolic stroke caused by Bartonella henselae (B. henselae) IE. Following a comprehensive review of the literature, it appears that only a small number of articles have reported on the correlation between cerebrovascular accidents (CVAs) and Bartonella IE. Here, we present a case of a 42-year-old male with a cerebral embolic event as a complication of B. henselae IE.
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Affiliation(s)
- Kipson Charles
- Internal Medicine, University of Central Florida College of Medicine, Graduate Medical Education/Hospital Corporation of America (HCA) Florida, North Florida Hospital, Gainesville, USA
| | - Andrew Abraham
- Internal Medicine, University of Central Florida College of Medicine, Graduate Medical Education/Hospital Corporation of America (HCA) Florida, North Florida Hospital, Gainesville, USA
| | - Raghav Bassi
- Internal Medicine, University of Central Florida College of Medicine, Graduate Medical Education/Hospital Corporation of America (HCA) Florida, North Florida Hospital, Gainesville, USA
| | - Rabab Elsadek
- Internal Medicine, University of Central Florida College of Medicine, Graduate Medical Education/Hospital Corporation of America (HCA) Florida, North Florida Hospital, Gainesville, USA
| | - George Cockey
- Internal Medicine, University of Central Florida College of Medicine, Graduate Medical Education/Hospital Corporation of America (HCA) Florida, North Florida Hospital, Gainesville, USA
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6
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Gromke M, Beard B. Non-bacterial Thrombotic Endocarditis Related to Squamous Cell Carcinoma of the Cervix. Cureus 2023; 15:e42128. [PMID: 37602093 PMCID: PMC10437085 DOI: 10.7759/cureus.42128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/22/2023] Open
Abstract
We report the case of a 51-year-old woman who presented with multiple thrombotic events, including deep vein thrombosis, extensive pulmonary embolisms, myocardial infarction, and multiple ischemic strokes suggesting cardiogenic embolization. Recent history was significant for locally advanced squamous cell carcinoma of the cervix. Echocardiogram revealed large aortic valve vegetations in the absence of evidence of infectious endocarditis consistent with the diagnosis of non-bacterial thrombotic endocarditis (NBTE). This case is a rare presentation of NBTE associated with squamous cell carcinoma of the cervix.
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Affiliation(s)
- Megan Gromke
- Oncology, Edward Via College of Osteopathic Medicine, Blacksburg, USA
| | - Bryce Beard
- Radiation Oncology, Rapides Regional Medical Center, Alexandria, USA
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7
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Mirzai S, Badwan OZ, Sankar PR, Karmali R, Almaaitah S, Gomes MP, Miyasaka R, Quatromoni N, Tong MZY, Wassif H. Ross procedure after prosthetic valve thrombosis in a patient with antiphospholipid syndrome and recurrent bleeding. Int J Rheum Dis 2023. [PMID: 36808218 DOI: 10.1111/1756-185x.14596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 01/15/2023] [Accepted: 01/18/2023] [Indexed: 02/23/2023]
Abstract
The Ross procedure allows replacement of a diseased aortic valve with pulmonary root autograft, possibly avoiding the highly thrombotic mechanical valves and immunologic deterioration of tissue valves in antiphospholipid syndrome (APS). Here, we present the use of the Ross procedure in a 42-year-old woman with mild intellectual disability, APS, and a complex anticoagulation history after she presented with thrombosis of her mechanical On-X aortic valve previously implanted for non-bacterial thrombotic endocarditis.
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Affiliation(s)
- Saeid Mirzai
- Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Rehan Karmali
- Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Saja Almaaitah
- Rheumatologic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marcelo P Gomes
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rhonda Miyasaka
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Neha Quatromoni
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Heba Wassif
- Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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8
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Muacevic A, Adler JR, Arad A, Kalmnovich G, Herzog E. Multi-Valvular Non-bacterial Thrombotic Endocarditis Causing Sequential Pulmonary Embolism, Myocardial Infarction, and Stroke: A Case Report and Literature Review. Cureus 2022; 14:e32261. [PMID: 36620810 PMCID: PMC9815786 DOI: 10.7759/cureus.32261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 12/12/2022] Open
Abstract
Non-bacterial thrombotic endocarditis is an uncommon entity that tends to be related to malignancy or rheumatological disorders. The diagnosis is complex and requires a high index of suspicion. It commonly causes recurrent emboli; however, coronary embolism remains an infrequently reported entity. Herein we report a unique case of sequential pulmonary embolism, ST-elevation myocardial infarction (MI), and stroke associated with multi-valvular non-bacterial thrombotic endocarditis. The cornerstone of management is treating the underlying cause and anticoagulation therapy. Surgical treatment should be considered in patients with acute heart failure secondary to valvular dysfunction and recurrent thromboembolism despite proper anticoagulation. We have performed an extensive literature search and found nine cases of established antemortem diagnosis of myocardial infarction secondary to non-bacterial thrombotic endocarditis, and we reviewed them according to cause, treatment, and outcome.
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9
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Savarapu P, Abdelazeem B, Isa S, Baral N, Hassan M. Cancer-Related Non-Bacterial Thrombotic Endocarditis Presenting as Acute Ischemic Stroke. Cureus 2021; 13:e14953. [PMID: 34123650 PMCID: PMC8190829 DOI: 10.7759/cureus.14953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2021] [Indexed: 11/05/2022] Open
Abstract
Non-bacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, is a rare form of noninfectious endocarditis presenting with thromboembolism including ischemic cerebral stroke. It is mostly associated with advanced malignancy and characterized by the presence of sterile vegetation on heart valves. The diagnosis is usually based on vegetations seen on an echocardiogram, with negative blood cultures suggesting a noninfectious etiology. The treatment for this condition includes systemic anticoagulation. In this report, we discuss the case of a 61-year-old Caucasian female who presented to our facility with an ischemic stroke. She was found to have vegetations on the mitral valve with negative blood cultures. Further studies revealed metastatic pancreatic cancer. The patient's condition improved following in-hospital management, and she was discharged home for outpatient follow-up and treatment. Through this report, we highlight the importance of considering a search for malignancy in patients presenting with these clinical features. Early diagnosis and prompt management are critical to reduce the complications of NBTE and improve the patients' quality of life.
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Affiliation(s)
- Pramod Savarapu
- Internal Medicine, McLaren Flint/Michigan State University, Flint, USA
| | - Basel Abdelazeem
- Internal Medicine, McLaren Flint/Michigan State University, Flint, USA
| | - Sakiru Isa
- Internal Medicine, McLaren Flint/Michigan State University, Flint, USA
| | - Nischit Baral
- Internal Medicine, McLaren Flint/Michigan State University, Flint, USA
| | - Mustafa Hassan
- Cardiology, Michigan State University College of Human Medicine, Flint, USA
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10
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Chan KH, Joseph O, Ahmed E, Kommidi A, Suleiman A, Szabela ME, Slim J. Marantic Endocarditis Associated with COVID-19: A Rare Case Report of a Potentially Deadly Disease. Eur J Case Rep Intern Med 2021; 8:002409. [PMID: 33869101 DOI: 10.12890/2021_002409] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 03/02/2021] [Indexed: 11/05/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) has overwhelmed healthcare globally with millions of cases and over 2 million deaths worldwide. The hypercoagulable state associated with COVID-19 is a well-recognized complication that carries a poor prognosis. Marantic endocarditis, or non-bacterial thrombotic endocarditis (NBTE), is caused by a sterile vegetation on the cardiac valves resulting from the deposition of fibrin and platelet aggregates. It is highly associated with the hypercoagulable and acquired inflammatory states. Herein, we report a unique and rare case of COVID-19 presenting with NBTE. LEARNING POINTS COVID-19 has caused a major global pandemic, with high morbidity and mortality.One of the complications of COVID-19 infection is a hypercoagulable state.To the best of our knowledge, we present only the second case of marantic endocarditis in a patient with COVID-19, in the hope of raising awareness among physicians of this potential rare association.
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Affiliation(s)
- Kok Hoe Chan
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| | - Ormena Joseph
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| | - Eyad Ahmed
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| | - Apoorva Kommidi
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| | - Addi Suleiman
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA.,Department of Cardiology, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| | - Maria E Szabela
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA.,Department of Infectious Disease, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
| | - Jihad Slim
- Department of Medical Education, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA.,Department of Infectious Disease, Saint Michael's Medical Centre, New York Medical College, Newark, New Jersey, USA
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11
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Ilyas S, Lang W, Belani N, Stockwell P. Non-Bacterial Thrombotic Endocarditis as a Cause of Cryptogenic Stroke in Malignancy. R I Med J (2013) 2021; 104:63-66. [PMID: 33648323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Non-bacterial thrombotic endocarditis (NBTE) is characterized by the deposition of fibrin and platelet thrombi on previously undamaged heart valves in the absence of bloodstream infection. It is associated with chronic disease states and can present with systemic embolic disease. Here we report a case of NBTE presenting as recurrent strokes in a patient with bladder cancer. Importantly, transthoracic echocardiography has limitations to detecting valvular lesions in NBTE, and providers should consider obtaining transesophageal echocardiography in the setting of high clinical suspicion.
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Affiliation(s)
- Suleman Ilyas
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence RI
| | - William Lang
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence RI
| | - Neel Belani
- Department of Medicine, Warren Alpert Medical School of Brown University, Providence RI
| | - Philip Stockwell
- Department of Medicine, Division of Cardiology, Warren Alpert Medical School of Brown University, Providence RI
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12
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Garcia RA, Guragai N, Vasudev R, Randhawa P, Habib MG. Rare Association of Non-Bacterial Thrombotic Endocarditis, Myocardial Infarction, and Acute Limb Ischemia Secondary to Rheumatoid Arthritis: Comprehensive Case Series With Literature Review. Cureus 2021; 13:e13319. [PMID: 33747642 PMCID: PMC7962500 DOI: 10.7759/cureus.13319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Most cases of non-bacterial thrombotic endocarditis (NBTE) tend to be related to malignancy or rheumatologic and autoimmune disorders like systemic lupus erythematosus. Rheumatoid arthritis (RA) itself has been associated with increased atherosclerosis, coronary artery plaque formation, and endothelial damage. However, it is rare to see NBTE in RA, simultaneously presenting with the acute coronary syndrome and acute limb ischemia due to distant embolization. Here we present a case of a 46-year-old female presenting with chest pain and right leg numbness, found to have ST-elevation myocardial infarction (STEMI) and occlusion of a peripheral artery due to embolization of vegetation present in the aortic valve. We also provide an extensive literature review of the relationship between NBTE and MI. One must be extra vigilant in managing these patients, especially if the size of vegetation is large as it has a tendency to embolize causing devastating complications.
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Affiliation(s)
| | - Nirmal Guragai
- Cardiology, Saint Joseph's Regional Medical Center, Paterson, USA
| | - Rahul Vasudev
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
| | - Preet Randhawa
- Cardiology, Trinitas Regional Medical Center, Elizabeth, USA.,Cardiology, Saint Michael's Medical Center, Newark, USA
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13
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Perrone F, Biagi A, Facchinetti F, Bozzetti F, Ramelli A, Vezzani A, Manca T, Gnetti L, Majori M, Alfieri V, Tiseo M. Systemic thromboembolism from a misdiagnosed non-bacterial thrombotic endocarditis in a patient with lung cancer: A case report. Oncol Lett 2020; 20:194. [PMID: 32952663 PMCID: PMC7479525 DOI: 10.3892/ol.2020.12056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 03/05/2020] [Indexed: 12/03/2022] Open
Abstract
Thromboembolic events are frequent in patients with cancer, commonly involving the venous and pulmonary circulation. The arterial system is rarely implicated in embolism and, when involved, a cardiogenic origin should always be excluded. In the present study, a case of a patient who developed multiple embolic events concomitantly with the diagnosis of locally-advanced non-small cell lung cancer with high expression levels of programmed death-ligand 1 (PD-L1) in >50% of tumor cells is reported. A cardiac defect interpreted as a patent foramen ovale required low molecular weight heparin administration. Despite the anti-coagulant therapy, before first-line anticancer treatment with pembrolizumab immunotherapy could be administered due to high PD-L1 expression levels, a new hospitalization was required due to the onset of novel ischemic manifestation. New transthoracic and transesophageal echocardiography revealed a previously misdiagnosed vegetation of the mitral valve that caused systemic embolization. The lack of any sign of infection led to the diagnosis of a non-bacterial thrombotic endocarditis (NBTE), whose embolic sprouting gave rise to the widespread ischemic events. No active anticancer treatment was feasible due to the rapid progression of the disease. NBTE can evolve quickly, eventually preventing any chance of treatment targeting the primary cause, which in the present study was lung cancer. If NBTE can be correctly diagnosed sooner then there may be the potential for anticancer therapy that does not worsen the hypercoagulability state, thus improving cancer-associated survival.
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Affiliation(s)
- Fabiana Perrone
- Medical Oncology Unit, University Hospital of Parma, I-43126 Parma, Italy
| | - Andrea Biagi
- Cardiology Department, University Hospital of Parma, I-43126 Parma, Italy
| | - Francesco Facchinetti
- Medical Oncology Unit, University Hospital of Parma, I-43126 Parma, Italy.,National Institute of Health and Medical Research, Gustave Roussy Cancer Campus, University of Paris-Saclay, 94800 Villejuif, France
| | | | - Andrea Ramelli
- Cardiac Surgery Intensive Care Unit, University of Parma, I-43126 Parma, Italy
| | - Antonella Vezzani
- Cardiac Surgery Intensive Care Unit, University of Parma, I-43126 Parma, Italy
| | - Tullio Manca
- Cardiac Surgery Intensive Care Unit, University of Parma, I-43126 Parma, Italy
| | - Letizia Gnetti
- Unit of Pathology, University of Parma, I-43126 Parma, Italy
| | - Maria Majori
- Unit of Pulmonology and Thoracic Endoscopy, University of Parma, I-43126 Parma, Italy
| | - Veronica Alfieri
- Unit of Respiratory Disease and Lung Function, University of Parma, I-43126 Parma, Italy
| | - Marcello Tiseo
- Medical Oncology Unit, University Hospital of Parma, I-43126 Parma, Italy.,Department of Medicine and Surgery, University of Parma, I-43126 Parma, Italy
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14
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Bussani R, DE-Giorgio F, Pesel G, Zandonà L, Sinagra G, Grassi S, Baldi A, Abbate A, Silvestri F. Overview and Comparison of Infectious Endocarditis and Non-infectious Endocarditis: A Review of 814 Autoptic Cases. In Vivo 2020; 33:1565-1572. [PMID: 31471406 DOI: 10.21873/invivo.11638] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 07/01/2019] [Accepted: 07/05/2019] [Indexed: 01/09/2023]
Abstract
AIM We examined evidence on infective and non-infective endocarditis obtained from a database of 50,403 clinical autopsies performed at an Italian general hospital between January 1983 and December 2006. MATERIALS AND METHODS Out of 814 endocarditis cases, 409 were of infective endocarditis (IE) and 405 non-infective (NIE). The median age at the time of death was 78 years for those with IE and 83 for those with NIE. Data were collected on gender, clinical history, comorbidities, kind of affected valve (non-prosthetic/mechanical/biological), pathological features of endocarditis, endocarditis complications and microbiological agents. RESULTS The diagnosis of IE was frequently missed and these conditions were often complicated by cardiovascular events. IE was more common among patients with prior valve infection or cardiovascular surgery, while malignancies were frequent comorbidities of NIE. CONCLUSION In general, we found several data that differ from those generally present in the scientific literature, and this could be explained by the fact that data on IE and NIE are generally obtained from surgical and clinical databases, while we analysed only autoptic cases.
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Affiliation(s)
- Rossana Bussani
- Institute of Pathological Anatomy, Riuniti Hospital and University of Trieste, Trieste, Italy
| | - Fabio DE-Giorgio
- Institute of Public Health, Section of Legal Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuliano Pesel
- Institute of Pathological Anatomy, Riuniti Hospital and University of Trieste, Trieste, Italy
| | - Lorenzo Zandonà
- Institute of Pathological Anatomy, Riuniti Hospital and University of Trieste, Trieste, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Riuniti Hospital and University of Trieste, Trieste, Italy
| | - Simone Grassi
- Institute of Public Health, Section of Legal Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alfonso Baldi
- Department of Environmental, Biological and Pharmaceutical Sciences and Technologies, L. Vanvitelli University of Campania, Caserta, Italy
| | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, U.S.A
| | - Furio Silvestri
- Institute of Pathological Anatomy, Riuniti Hospital and University of Trieste, Trieste, Italy
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15
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Gundersen H, Moynihan B. An Uncommon Cause of Stroke: Non-bacterial Thrombotic Endocarditis. J Stroke Cerebrovasc Dis 2016; 25:e163-4. [PMID: 27449112 DOI: 10.1016/j.jstrokecerebrovasdis.2015.11.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 08/11/2015] [Accepted: 11/05/2015] [Indexed: 12/15/2022] Open
Abstract
Our objective is to present the case of an uncommon but probably under-recognized cause of stroke: Non-bacterial thrombotic endocarditis (NBTE). A 59-year-old man presented to our hospital with multiple bihemispheric infarcts despite taking rivaroxaban for pulmonary emboli diagnosed 2 weeks earlier. The patient's symptoms progressed quickly and he died within a week of his initial presentation despite attempts at neuroradiologically guided clot retrieval and early recognition and treatment of disseminated intravascular coagulation. On postmortem examination it was discovered that he had an undiagnosed squamous cell adenocarcinoma of the lung and NBTE. NBTE is difficult to diagnose and difficult to treat. It is associated with a mortality rate and is often not diagnosed until autopsy. However there are case reports in the literature where NBTE has been successfully treated. Early recognition and prompt treatment of the underlying disease process is the essential first step.
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16
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Elikowski W, Jarząbek R, Małek M, Witczak W, Łazowski S, Psuja P. [ Non-bacterial thrombotic endocarditis on the bicuspid aortic valve in a 25-year-old male with lupus anticoagulant]. Pol Merkur Lekarski 2016; 40:182-185. [PMID: 27088201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Non-bacterial thrombotic endocarditis (NBTE) is characterized by presence of sterile vegetations that develop from fibrin and platelets on heart valves. The main conditions predisposing to NBTE are malignancy, autoimmune diseases and other hypercoagulable states. The authors describe a case of a 25-year-old male, in whom NBTE was diagnosed on the bicuspid aortic valve. The presence of significant aortic regurgitation and dental caries were initially suggestive of infective endocarditis; although, serial blood culture were negative and procalcytonin concentration was within normal ranges. Empiric antibiotic therapy did not result in diminishing of vegetations, similarly to the anticoagulation treatment initiated when strongly positive lupus anticoagulant was detected in laboratory findings. Aortic valve replacement was necessary. Bacteriologic examination of the excised valve was negative. Widespread fibrin masses at different stages of organization on the leaflets confirmed NBTE in histopathologic assessment. Lupus anticoagulant was probably secondary to thyroid autoimmune disease.
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Affiliation(s)
| | | | - Małgorzata Małek
- Karol Marcinkowski Medical University of Poznań, Poland, 2ndDepartment of Cardiology
| | | | | | - Piotr Psuja
- Józef Struś Hospital, Poznań, Poland: Department of Internal Medicine
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