Malignancy-driven hypercoagulability: a fatal combination.

Abstract

A 78-year-old woman, known with type 2 diabetes and paroxysmal atrial fibrillation, presented with fatigue, weight loss, and confusion. There was no fever, but physical examination revealed extensive petechiae and a loud systolic and diastolic heart murmur. Lab results showed acute kidney failure (creatinine 2.64 mg/dL) and mild inflammation [C-reactive protein (CRP) 26.8 mg/L]. Coagulation tests were found to be abnormal with elevated D-dimers (>7000 µg/L), international normalized ratio (INR) of 3.8, and marked thrombocytopaenia (41.000/µL) suggesting disseminated intravascular coagulation. Due to deteriorating neurological status, a computed tomography (CT) scan of the brain was performed which showed diffuse ischaemic lesions suspicious for a cardioembolic source. Transoesophageal echocardiography demonstrated very thick non-mobile vegetations on the aortic valve, causing severe valvular regurgitation (Figure 1A–C). The leaflets of the mitral valve were also thickened with the presence of mobile structures on the atrial side, highly suggestive of endocarditis (Figure 1A). Repeated blood cultures were negative.