MASSIVE STROKE ON ANTICOAGULATION; A CASE OF NONBACTERIAL THROMBOTIC ENDOCARDITIS IN A PATIENT WITH LUNG ADENOCARCINOMA

Abstract

SESSION TITLE: Lung Cancer 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Non Bacterial Thrombotic Endocarditis (NBTE) is a rare condition that refers to noninfectious lesions of the heart valves. 80% of the cases are associated with advanced malignancy. When compared to other malignancies, higher rates are observed in patients with adenocarcinoma. (1) We present a case of massive stroke in a patient with NBTE secondary to Stage IV Lung Adenocarcinoma (LA) while on Apixaban. CASE PRESENTATION: 56y.o. male with no significant past medical history presented with abdominal pain and worsening shortness of breath. On further evaluation, he was noted to have splinter hemorrhages as well. Additional workup revealed multiple pulmonary nodules, hilar and mediastinal lymphadenopathy. A biopsy was obtained which was consistent with Lung Adenocarcinoma. PET Scan revealed metastatic activity in the neck and mediastinum. He was also found to have bilateral extensive Deep Vein Thrombosis in the lower extremities. Transesophageal Echocardiogram demonstrated a 3x4 mm mass on the anterior leaflet of the mitral valve. All infectious workup was negative and a diagnosis of NBTE was made. Treatment with low molecular weight heparin was discussed but patient refused, and consequently was sent home on Apixaban. Two weeks later, he was found down at his residence. Upon arrival to Emergency Department, he was noted to have complete left sided hemi neglect. Brain imaging revealed non-reversible ischemia in right Middle Cerebral Artery Territory. Mitral valve vegetation was the likely culprit. Computed Tomography (CT) of the head revealed hemorrhagic transformation. No further neurologic or cardiac intervention was performed. The patient was eventually discharged on Rivaroxaban and was instructed to follow up with his oncologist for initiation of chemotherapy. DISCUSSION: It's well known that low molecular weight heparin (LMWH) is the first choice for anticoagulation in NBTE secondary to malignancy, (1) nevertheless the patient refused it so he was placed on Apixaban instead, proving unfortunately to be ineffective. Anticoagulation with this medication has yet to be evaluated in patients with NBTE. Recent studies point out that Rivaroxaban and Edoxaban are comparable to (LMWH) in preventing Venous Thromboembolism and further embolic episodes caused by NBTE (2,3). CONCLUSIONS: Vegetations in NBTE vary in size from microscopic to large and exuberant. They can easily dislodge and cause embolic phenomena. LMWH, Rivaroxaban or Edoxaban should always be considered in these type of patients. Further investigation is required regarding other oral anticoagulants. We hope that clinicians can take our case as reference as properly managing these patients will have a dramatic impact on quality of live and even life expectancy. Reference #1: Mazokopakis EE, Syros PK, Starakis IK. Nonbacterial thrombotic endocarditis (marantic endocarditis) in cancer patients. Cardiovasc Hematol Disord Drug Targets 2010; 10:84. Reference #2: Gary E. et al. Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism. N Engl J Med 2018; 378:615-624 Reference #3: Young A. et al Anticoagulation Therapy in Selected Cancer Patients at Risk of Recurrence of Venous Thromboembolism: Results of the Select-D Pilot Trial. Thromb Res. 2016 Apr;140 Suppl 1:S172-3. DISCLOSURES: No relevant relationships by Girish Balachandran Nair, source=Web Response No relevant relationships by Fernando Figueroa Rodriguez, source=Web Response no disclosure on file for Hira Iftikhar