Non-bacterial thrombotic endocarditis associated with Trousseau's syndrome.

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A 72-year-old Japanese woman with recent multiple cerebral infarctions was referred to our clinic for cardiac evaluation. Brain magnetic resonance imaging showed multiple cerebral infarctions in the right hemisphere (Fig. 1a, b). Regular and continuous monitoring ECG showed normal sinus rhythm and there was no symptom or sign suggesting the occurrence of paroxysmal atrial fibrillation. Laboratory findings demonstrated a thrombocytopenia with platelets of 8.0 9 10/ll, and elevations of fibrin degradation product at 58.7 lg/ml and D-dimer at 20.0 lg/ml. A series of blood cultures was negative. Echocardiography revealed an abnormal mass with relatively low echo intensity attached to the anterior mitral leaflet, moving with heart beats (Fig. 1c, d) which suggested the presence of vegetation associated with or without infective endocarditis. Under these conditions, there was no mitral regurgitation. We temporarily suspected non-bacterial thrombotic endocarditis as the cause of multiple cerebral infarctions, although another possibility accompanying the abnormal mass directly attached to the mitral valve leaflet should be considered [1]. On her 7th hospital day, she complained of epigastralgia and had a gastrointestinal fiberscope examination which showed enlarged folds in the gastric corpus (Fig. 2). On histopathology of the biopsy specimens, poorly differentiated adenocarcinoma was diagnosed (Fig. 2, inset). On the basis of these findings, we diagnosed this case as Trousseau’s syndrome which exhibits a hypercoagulable state due to underlying cancers and can cause systemic thrombotic events [2]. Every type of cancer has been reported to be associated with Trousseau’s syndrome. Under these conditions, friable vegetations, often observed by echocardiography, are formed in cardiac valves, as also observed in the present case [3]. For the treatment, anticoagulation therapy is mainly considered for the possible occurrence of systemic embolism. Although anticoagulation therapy comprising heparin at 20000 U/day was started, the patient unfortunately died of the cerebral hemorrhage associated with recurrent cerebral infarctions. We suggest that the possible existence of Trousseau’s syndrome is considered when one finds vegetation-like images in echocardiography. K. Nakashima T. Haraki H. Hirase Department of Cardiology, Takaoka City Hospital, Takaoka, Japan