Non-infectious thrombotic endocarditis associated with chronic rheumatic heart disease and disseminated tuberculosis.

Aravind Sekar,Sanjeev Naganur

doi:10.4322/acr.2021.269

Abstract

ABSTRACTRheumatic heart disease is still common in developing countries and requires prompt intervention to prevent chronic complications. Vegetations in rheumatic heart disease might be due to acute episodes of rheumatic fever itself or due to either infective endocarditis (IE) or Non-infectious thrombotic endocarditis (NITE). Each form of vegetations has specific pathological characteristics on gross and microscopic examination. However, clinically IE and NITE may have overlapping signs and symptoms. A chance of misdiagnosis of NITE as culture-negative infective endocarditis is higher if the former present with infective symptoms like fever. NITE of valves can be due to underlying associated malignant neoplasm, particularly mucinous adenocarcinoma, pneumonia, cirrhosis, autoimmune disorders, and hypercoagulable state. The coexistence of tuberculosis, non-infectious thrombotic endocarditis and rheumatic valvular heart disease was rarely documented in medical literature. We describe a case of chronic rheumatic heart disease with vegetations in the posterior mitral valve leaflet, treated as culture-negative infective endocarditis, which, at autopsy, reveals the presence of Nonbacterial thrombotic endocarditis vegetation over calcified, fibrosed mitral valve leaflets and associated disseminated tuberculosis along with classic pathological sequela findings of chronic rheumatic mitral valvular heart disease in lungs and liver.

Highlights

Chronic rheumatic valvular heart disease is a worrisome complication of rheumatic fever, in developing countries, and requires prompt surgical intervention to prevent further sequela of disease.[1]
We describe an autopsy case of chronic rheumatic heart disease associated with non-infectious thrombotic endocarditis over damaged posterior mitral valve leaflet and disseminated tuberculosis
In a large autoptic series by Bussani et al.[4] the incidence of NBTE in the autopsy was found to be 3.7% and higher than that of infective endocarditis (1.1%). They observed that when compared to infective endocarditis, NBTE was more frequently developed on pre-existing valvular lesions, including rheumatic heart disease (35% vs. 13%)

Summary

INTRODUCTION

Chronic rheumatic valvular heart disease is a worrisome complication of rheumatic fever, in developing countries, and requires prompt surgical intervention to prevent further sequela of disease.[1]. A 35-year-old man with a prior clinical diagnosis of rheumatic heart disease with severe mitral stenosis presented to the outpatient department with complaints of worsening dyspnea He could not be submitted to mitral valve replacement due to financial constraints and was on medical management for 4 years. He was planned for mitral valve replacement He developed worsening of dyspnea with orthopnea along with new-onset fever associated with chills; He was initially managed on a line of cardiogenic shock with pulmonary edema; started on inotropic support along with non-invasive ventilation His shock was worsening and mean arterial pressure failed to normalize despite three inotropes at maximal dosage Despite all supportive measure his vitals continued to decline and he went into asystole.

AUTOPSY FINDINGS

DISCUSSION

CONCLUSION