A RARE BUT DEADLY DIFFERENTIAL: MARANTIC ENDOCARDITIS

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Marantic endocarditis, also called NonBacterial Thrombotic Endocarditis (NBTE), is a condition that signifies noninfectious lesions or vegetations to the endocardium. It is a very rare pathological finding seen in advanced stages of malignancy and typically found at a rate of 0.9-1.6% of autopsy [1]. NBTE is commonly found in advanced cases of adenocarcinoma and typically affects the aortic and mitral valves. Vegetations have a higher predilection to dislodge due to the lack of inflammatory reaction leading to a shower phenomenon. Due to this limited understanding patients with adenocarcinoma and incidental pulmonary embolism findings should have transesophageal echocardiograms (TEE) performed to prevent debilitating complications such as cerebrovascular accidents (CVA). CASE PRESENTATION: A 70 year old male presented to the hospital with CVA symptoms of aphasia after waking up. The wife reported that the patient was completely coherent the night before presentation and next morning was unable to speak. He did not demonstrate any motor deficits. Only relevant complain was that patient had a severe headache in the night prior going to bed. Pertinent history was that the patient has had ongoing issues with abdominal pain a few months leading up to presentation. His primary care ordered a CT abdomen scan that found 6.4cm right hepatic mass that was highly suspicious for malignancy along with incidental pulmonary embolism (PE) finding in the right lower lobe of the lung. He had been started on Eliquis due to these findings and this was held for two days in order to have a CT guided biopsy. On admission patient had a CT head that was negative for hemorrhagic stroke. MRI brain revealed multiple embolic lesions suspicious for cardiac etiology. Patient was kept on telemetry but there were no pertinent findings of dysrhythmias. Given incidental findings of PE a Transthoracic echocardiogram (TTE) was performed with bubble study that was negative for a shunt. Finally, a TEE was performed and patient was reported to have severe marantic endocarditis. DISCUSSION: Given the presentation of the case above it is imperative to do a thorough workup for patients presenting with incidental findings of a PE and high suspicion for an underlying malignant process. Although right heart lesions are rare in marantic endocarditis it is highly likely that his incidental PE finding could have been a result of right sided vegetation dislodgement. An early workup with TEE could have helped detect his marantic endocarditis prior to his CVA and improve his quality of life. CONCLUSIONS: Even though the incidence of marantic endocarditis remains low it must be considered as part of the differential when a patient with suspected malignant process presents with CVA symptoms. Early detection and increased awareness will lead to proper selection of anticoagulation in order to prevent further complications and improve morbidity. Reference #1: Eiken PW, Edwards WD, Tazelaar HD, McBane RD, Zehr KJ. Surgical pathology of nonbacterial thrombotic endocarditis in 30 patients, 1985-2000. Mayo Clin Proc. 2001;76(12):1204-1212. doi:10.4065/76.12.1204 DISCLOSURES: No relevant relationships by Gilbert-Roy Kamoga, source=Web Response No relevant relationships by Shoaib Khan, source=Web Response