Nonbacterial Thrombotic Endocarditis Research Articles

A rare case of prostatic ductal adenocarcinoma presenting as papillary metastatic carcinoma of unknown primary: A case report and review of the literature

Prostatic ductal adenocarcinoma is an uncommon form of prostatic carcinoma. We report a case of a 63-year-old man who presented with non-infective thrombotic (marantic) endocarditis and an incidental finding of a destructive lesion in the left iliac crest. Core biopsy of the lesion showed a carcinoma with papillary architecture and was initially diagnosed as “metastatic carcinoma of unknown origin”. The patient experienced a cerebral infarction and expired six days later. Postmortem examination revealed extensive mixed acinar and ductal adenocarcinoma (Gleason score 5+4=9) in the prostate. Further studies confirmed the bone lesion as metastatic prostatic ductal adenocarcinoma. Although rare, metastatic prostatic adenocarcinoma should be considered in the differential diagnosis in a male patient when the carcinoma shows predominantly papillary architectures. A review of literature is presented to enhance the awareness of this entity.

Non-Bacterial Thrombotic Endocarditis in a Patient with Rheumatoid Arthritis.

Rheumatoid arthritis (RA) is frequently associated with various extra-joint complications. Although rare, thromboembolic complications are associated with high morbidity and mortality. We experienced a very rare case of nonbacterial thrombotic endocarditis (NBTE) and subsequent embolic stroke in a patient with RA. A 72-year-old male with a 15-year history of RA suddenly developed neurologic symptoms of vomiting and dizziness. Brain magnetic resonance imaging revealed recently developed multiple cerebellar and cerebral lacunar infarctions. Echocardiography showed a pulsating mitral valve vegetation involving the posterior cusp of the mitral valve leaflet, which was confirmed as NBTE. Immediate anti-coagulation therapy was started. The NBTE lesion disappeared in follow-up echocardiography after 4 weeks of anti-coagulation treatment.

Cotton Wool Spots in Trousseau’s Syndrome

Trousseau’s syndrome is a paraneoplastic disorder characterized by a hypercoagulable state inducing either migratory superficial thrombophlebitis or arterial emboli from a nonbacterial thrombotic endocarditis. Cotton wool spots (CWS) are usually asymptomatic and represent small areas of retinal infarction. A 69 year-old man was investigated for multiple cerebral and cerebellar thromboembolic events and was found to harbour a metastatic pancreatic carcinoma.

Presentation of Gastric Adenocarcinoma with Acute Arterial Occlusive Disease, Nonbacterial Thrombotic Endocarditis and Pyogenic Liver Abscess

Fatal outcome at early presentation of cancer is rare. Here, a case is discussed of a 53 year old female that presented with an acute onset of left lower extremity pain with paleness, pulselessness, abdominal cramps and vomiting that had been present for several weeks. Rapid evaluation led to the initial diagnosis of metastasized gastric cancer that had evolved to hepatic abscedation and aortic valve endocarditis. The patient rapidly developed severe sepsis with multiple organ failure and died 48 hours after presentation.

Cancer-related Stroke due to Mural Thrombus in the Extracranial Carotid Artery

A 41-year-old man was admitted to our hospital because of a cancer-related stroke (CRS) caused by a thrombus of the extracranial carotid artery. He had undergone neoadjuvant radiochemotherapy for metastatic colorectal adenocarcinoma. The serum D-dimer values were within the normal range. We treated him with intravenous unfractionated heparin followed by warfarin. There were no recurrent stroke events over six months. The leading cause of a CRS is an embolism caused by hypercoagulopathy, mainly represented by non-bacterial thrombotic endocarditis. However, it was unusual that, in the current case, a thrombus of the extracranial carotid artery was formed with no significant residual stenosis, thus resulting in an artery-to-artery embolism.

臨床的に明らかな基礎疾患を認めなかった非細菌性血栓性心内膜炎の1例

臨床的に明らかな基礎疾患を認めなかった非細菌性血栓性心内膜炎の1例

Systemic embolic events with nonbacterial thrombotic endocarditis as manifestations of recurrent ovarian clear cell carcinoma

ObjectiveTo present a rare case of recurrent ovarian clear cell carcinoma (OCCC) with systemic embolic events. Case reportA 60-year-old woman with a history of OCCC presented with an acute ischemic stroke. Magnetic resonance imaging showed multifocal, bilateral infarctions over the cerebrum and cerebellum. An echocardiogram revealed vegetation growth in the mitral and tricuspid valves and showed no evidence of atrial fibrillation. The serological studies for stroke were negative for all assessed parameters (normal values of protein C, protein S, antithrombin III, and lupus anticoagulant antibodies). Computed tomography of the abdomen and pelvis revealed bilateral renal and splenic infarctions, as well as enlarged pelvic lymph nodes due to a recurrent ovarian neoplasm. We diagnosed the patient with nonbacterial thrombotic endocarditis (NBTE) based on serial negative blood cultures and sterile vegetation of the surgical specimen. ConclusionNBTE should be considered among the possible causes of multifocal embolic infarctions and as an early manifestation of recurrent OCCC. Anticoagulant therapy is the mainstay of treatment, and dual anticoagulation therapies are necessary to reduce the risk of recurrent thromboembolism.

Nonbacterial thrombotic endocarditis associated with chronic hypoxia and secondary polycythemia

A 72-year-old man with a past medical history significant for chronic obstructive pulmonary disease (COPD), witnessed nocturnal apnea and persistent 80-pack-year tobacco use presented with a new-onset of aphasia. MRI brain demonstrated restricted perfusion in the left temporoparietal area and insular cortex, consistent with subacute embolic strokes. Investigation for the etiology was notable for secondary polycythemia and non-specific mitral valve thickening on transthoracic echocardiography (TTE). Subsequent transesophageal echocardiography (TEE) showed a heterogenous,1.1 cm mass on the anterior mitral valve leaflet. Following warfarin bridge therapy, surgical resection revealed a sterile thrombus, consistent with nonbacterial thrombotic endocarditis (NBTE). Chronic hypoxia has been implicated in the pathogenesis of NBTE in both human and animal studies. While animal models have suggested a direct causal relationship, human studies are largely limited to isolated case reports, which have almost uniformly been confounded by the presence of other disorders of hypercoaguability, such as malignancy or disseminated intravascular coagulation (DIC). Unique in comparison to prior studies, this report demonstrates a case of NBTE in the setting of chronic oxygen deprivation and secondary polycythemia in a patient without any additional major risk factors.

A case series of non-bacterial thrombotic endocarditis associated with gynecological malignancies

Background: Ischemic stroke secondary to NBTE is a rare complication of systemic malignancies. Although previously reported in gynecological cancers, this occurrence is infrequent. Furthermore, stroke pre-dating the gynecological malignancy diagnosis has rarely been reported. Methods: Case presentations and literature review. Results: Case1: A 48-year-old woman presented with acute dysarthria and left facial weakness caused by a right middle cerebral artery (MCA) infarct. Mitral valve vegetations were found on a transthoracic echocardiogram (TTE). A malignancy screen uncovered a pelvic endometrial adenocarcinoma. Case 2: A 49-year-old woman developed acute right hand weakness. A CT head scan showed a left pre-central gyrus infarct. Her TEE revealed aortic valve vegetations. An ovarian neoplasm was then discovered. Case 3: A 36-year-old woman with a known diagnosis of cervical squamous cell carcinoma developed acute left-sided weakness secondary to a right MCA stroke. Aortic valve vegetations were seen on TTE. Conclusions: We have reported three cases of NBTE where the underlying malignancy was gynecological. In the first two cases, the malignancy was discovered while investigating for the stroke mechanism, while the third had a known underlying malignancy. This series highlights the need to consider gynecological malignancies as an underlying cause of stroke in young women; and that the ischemic event can occur prior to the malignancy diagnosis.

Diagnostic yield of echocardiography in cancer patients with ischemic stroke.

The yield of echocardiography in cancer patients with acute ischemic stroke is unknown. We identified adult patients with active systemic cancer diagnosed with acute ischemic stroke at a tertiary-care cancer center from 2005 through 2009 who underwent transthoracic (TTE) or transesophageal echocardiography (TEE). Two neurologists independently reviewed all clinical data, including TTE and TEE reports, and adjudicated whether echocardiographic studies revealed a definite or possible source of stroke according to pre-defined criteria. Patients were classified as having suspected cardioembolic strokes if imaging showed embolic-appearing infarcts in more than one vascular territory. Among 220 patients with cancer and ischemic stroke who underwent echocardiography, 216 (98%) had TTE and 37 (17%) had TEE. TTE revealed a definite source in 15 (7%, 95% CI 4-10%) patients and a possible source in 42 (19%, 95% CI 14-25%), while TEE revealed a definite source in 10 (27%, 95% CI 12-42%) patients and a possible source in 14 (38%, 95% CI 21-54%). In 92 patients with suspected cardioembolic strokes who underwent TTE, 6 (7%, 95% CI 1-12%) had a definite source, including 4 with marantic endocarditis, and 20 (22%, 95% CI 13-30%) had a possible source. Twenty-one of these patients also underwent TEE, which demonstrated a definite or possible source in 16 (76%, 95% CI 56-96%) patients, including marantic endocarditis in 4 (19%). The yield of TTE for detecting marantic endocarditis and other cardiac sources of stroke in cancer patients is low, but TEE may provide a higher yield in targeted patients.

In-hospital stroke recurrence and stroke after transient ischemic attack: frequency and risk factors.

We aimed to assess the risk of recurrent ischemic events during hospitalization for stroke or transient ischemic attack (TIA) with optimal current management and to identify associated risk factors. We performed a retrospective analysis of all patients treated for acute ischemic stroke or TIA in 3 stroke units between 2010 and 2013. Recurrent stroke was defined as new persisting (≥24 hours) neurological deficit occurring >24 hours after the index event and not attributable to other causes of neurological deterioration. Cox proportional hazard regression identified risk factors associated with recurrent stroke. The study included 5106 patients. During a median length of stay of 5 days (interquartile range, 4-8), stroke recurrence (or stroke after TIA) occurred in 40 patients (0.8%) and was independently associated with history of TIA, symptomatic carotid stenosis (≥70%), or other determined etiology. Patients with recurrent stroke and other determined etiology had cervical arterial dissection (n=2), primary angiitis of the central nervous system (n=1), giant cell arteritis (n=1), and lung cancer with nonbacterial thrombotic endocarditis (n=1). In patients with initial TIA or minor stroke (National Institutes of Health Stroke Scale ≤5) recurrence was associated additionally with pneumonia after the inciting ischemic event but before stroke recurrence. Patients with initial stroke and aphasia had a lower stroke recurrence rate and there were no recurrences in patients with lacunar stroke. Recurrence was associated with significantly higher in-hospital mortality (17.5% versus 3.1%; P<0.001). In-hospital stroke recurrence was low with optimal current management. Patients with a history of TIA, severe symptomatic carotid stenosis, or uncommon causes of stroke were at higher risk. Pneumonia was associated with a higher risk of stroke recurrence in patients with initial TIA or minor stroke but not in the overall population studied. Aphasia may bias the detection rate by concealing new neurological symptoms.

Right ventricular marantic endocarditis

A 68-year-old female presented with chest pain and breathlessness. She had breast carcinoma treated 17 years ago, with further surgical excision for recurrence 7 years ago. Computerised tomography (CT) demonstrated bi-lateral pulmonary embolism, with extensive lymphadenopathy and lung metastases. She was treated with therapeutic heparin. Echocardiography revealed a right ventricular mass attached to the tricuspid valve chordae (Fig. 1; Videos 1 and 2), which could be thrombus, marantic or infective vegetation. Blood cultures were negative. Lymph node biopsy showed malignant cells, likely of breast origin. Despite therapeutic anti-coagulation, echocardiogram 3 weeks after initial presentation demonstrated enlargement of the original mass and an additional mass (Fig. 1; Videos 3 and 4), implying that these were most probably marantic. We retrospectively reviewed the CT performed at first presentation, which also demonstrated the original right ventricular mass (Fig. 1). She died from recurrent embolic cerebrovascular events, confirmed on MRI, within a month from initial presentation. In advanced stages of malignancy, marantic endocarditis or non-bacterial thrombotic endocarditis can develop in hypercoagulable states. It has a rapidly progressive course, with embolisation of vegetations to other organs. The sterile vegetations consist of fibrin and platelets (1, 2). Patients should be anti-coagulated. In terminal cases, surgery rarely alters the final outcome (2, 3). Figure 1 (A and B) Right ventricular mass (arrowed) attached to the tricuspid valve chordae apparatus on echocardiography, in apical four-chamber view, and modified parasternal right ventricular inflow view respectively; (C and D) repeat echocardiogram demonstrating ... Video 1 The initial right ventricular mass attached to the tricuspid valve chordae apparatus on echocardiography, in modified parasternal right ventricular inflow view. Download Video 1 via http://dx.doi.org/10.1530/ERP-14-0066-v1 Download Video 1 Video 2 The initial right ventricular mass attached to the tricuspid valve chordae apparatus on echocardiography, in apical four-chamber view. Download Video 2 via http://dx.doi.org/10.1530/ERP-14-0066-v2 Download Video 2 Video 3 Repeat echocardiogram demonstrating enlargement of the original mass and an additional mass, in modified parasternal right ventricular inflow view. Download Video 3 via http://dx.doi.org/10.1530/ERP-14-0066-v3 Download Video 3 Video 4 Repeat echocardiogram demonstrating enlargement of the original mass and an additional mass, in apical four-chamber view. Download Video 4 via http://dx.doi.org/10.1530/ERP-14-0066-v4 Download Video 4

Nonbacterial Thrombotic Endocarditis in Association with Metastatic Mucin-Secreting Adenocarcinoma in Heart

Nonbacterial thrombotic endocarditis (NBTE) is characterized by the deposition of thrombi on cardiac valves in the absence of bloodstream bacterial infection. It is usually associated with advanced stage malignancy and chronic debilitating diseases. We present an autopsy case report of a 45-year-old man with NBTE in association with metastatic mucin-secreting adenocarcinoma involving the heart.

Synchronous Ovarian and Endometrial Endometrioid Adenocarcinoma Presenting with Nonbacterial Thrombotic Endocarditis and Pulmonary Thromboembolism: Adenocarcinoma with Thrombotic Events

Introduction. Nonbacterial thrombotic endocarditis (NBTE) is a rare manifestation of hypercoagulability in patients with malignant neoplasms. Case Report. A fifty-six-year-old woman presented to the emergency service; the clinical workup revealed deep vein thrombosis in right leg and bilateral massive PTE. As the abdominal sections on the spiral CT revealed a giant pelvic mass of ovarian origin, she was referred to our hospital's gynecologic oncology department. She was scheduled for surgery under enoxaparin. She described numbness on one side of her face. Cranial imaging findings revealed acute ischemic cerebral lesions and transesophageal echocardiogram showed vegetation on the aortic cusp. Under anticoagulation treatment, she underwent hysterectomy with bilateral salpingo-oophorectomy and infracolic omentectomy. After tumor resection, her neurological symptoms dissolved with aggressive anticoagulant treatment. Pathology result was synchronous endometrial and ovarian adenocarcinoma. Discussion. NBTE is a rare condition often associated with advanced malignancies. Peripheral embolism and venous thrombosis are complications that have been associated with NBTE due to hypercoagulable state. These disorders could be resistant to routine anticoagulant treatment. In case of a thrombotic complication due to ovarian malignancy, surgical resection of the primary tumor may increase the effect of anticoagulant treatment.

A Marantic Endocarditis Complicating a Metastatic Gastric Adenocarcinoma Initially Resistant to Low-molecular Weight Heparin: A Case Report

Background: Marantic endocarditis is a rare paraneoplastic syndrome which results from an hypercoagulate state. It can be associated with several tumors, particularly gastric cancer, and histology of adenocarcinoma. Mucines secreted by adenocarcinoma contribute to the activation of the coagulation pathway. Case presentation: We present the case of a patient with a marantic endocarditis complicating a metastatic gastric adenocarcinoma. He was hospitalised for a thoracic pain. At the physical examination, we found swelling, redness, and warmth of the right lower limb, suspected for a deep vein thrombosis that was confirmed at the echo doppler ultrasound. CT scan documented a severe bilateral pulmonary embolism, a splenic infarction, and multiple liver metastases. Laboratory tests were normal. Despite a Low-Molecular Weight Heparin (LMWH) treatment, the patient presented a cerebral stroke, confirmed at the MRI. Trans-thoracic echocardiography found a small vegetation of the mobile end of the mitral valve with a normal left ventricular contractile function. LMWH was switched by continuous intravenous Unfractionated Heparin (UFH). PET scan showed multiple liver metastases and a pathological gastric hypermetabolism. Liver biopsy confirmed a metastasis of a HER-2 negative gastric adenocarcinoma. Because of the stop of heparin treatment during this procedure, the patient presented a new brain stroke. A systemic palliative chemotherapy was started by FOLFOX-4 regimen and it is now ongoing. Conclusion: The particularity of this case relies on the impossibility to initially switch UFH by another anticoagulant treatment. Chemotherapy represents the only possibility to decrease mucine production and thrombi formation.

Hypercoagulability in Malignancy and a Rare Case of Embolıc Stroke as a Consequence of Nonbacterial Thrombotic Endocarditis in Ovarian Clear Cell Carcınoma

Hypercoagulability in Malignancy and a Rare Case of Embolıc Stroke as a Consequence of Nonbacterial Thrombotic Endocarditis in Ovarian Clear Cell Carcınoma

Stroke : Highlights of Selected Articles

<i>Stroke</i> : Highlights of Selected Articles

Cryptogenic subtype predicts reduced survival among cancer patients with ischemic stroke.

Cryptogenic stroke is common in patients with cancer. Autopsy studies suggest that many of these cases may be because of marantic endocarditis, which is closely linked to cancer activity. We, therefore, hypothesized that among patients with cancer and ischemic stroke, those with cryptogenic stroke would have shorter survival. We retrospectively analyzed all adult patients with active systemic cancer diagnosed with acute ischemic stroke at a tertiary care cancer center from 2005 through 2009. Two neurologists determined stroke mechanisms by consensus. Patients were diagnosed with cryptogenic stroke if no specific mechanism could be determined. The diagnosis of marantic endocarditis was restricted to patients with cardiac vegetations on echocardiography or autopsy and negative blood cultures. Patients were followed until July 31, 2012, for the primary outcome of death. Kaplan-Meier statistics and the log-rank test were used to compare survival between patients with cryptogenic stroke and patients with known stroke mechanisms. Multivariate Cox proportional hazard analysis evaluated the association between cryptogenic stroke and death after adjusting for potential confounders. Among 263 patients with cancer and ischemic stroke, 133 (51%) were cryptogenic. Median survival in patients with cryptogenic stroke was 55 days (interquartile range, 21-240) versus 147 days (interquartile range, 33-735) in patients with known stroke mechanisms (P<0.01). Cryptogenic stroke was independently associated with death (hazard ratio, 1.64; 95% confidence interval, 1.25-2.14) after adjusting for age, systemic metastases, adenocarcinoma histology, and functional status. Cryptogenic stroke is independently associated with reduced survival in patients with active cancer and ischemic stroke.

The Search for Cryptogenic Stroke, A Case of Marantic Endocarditis

Nonbacterial thrombotic endocarditis (NBTE) is rare and undoubtedly an under-recognized cause of cryptogenic stroke. Its diagnosis relies on a high index of clinical suspicion, particularly in patients with previous malignancy. We present a case of a young woman, with three neurologic events occurring in rapid succession over three weeks, ultimately resulting in her death. The echo imaging findings here appear relatively benign compared to the catastrophic consequences, and speaks of the aggressive fibrin and platelet deposition that can embolize widely in this condition, confirmed on the postmortem examination. We discuss the details of NBTE aiming to increase awareness while assessing patients with undetermined systemic embolization.

Concomitant presentation of myocarditis and non-bacterial thrombotic endocarditis in a patient with granulomatosis with polyangiitis

Granulomatosis with polyangiitis (GPA) is a necrotizing vasculitis. The etiology of the disease is not completely known. In this report, we describe a 47-year-old male who presented with ongoing dyspnea. He is a known case of GPA for 3 years based on skin biopsy and positive antineutrophil cytoplasmic antibody. The electrocardiogram showed changes suggestive for myocarditis. A transthoracic and trans esophageal echocardiogram revealed left ventricular systolic dysfunction, thickened left atrial and ventricular wall and vegetation on mitral valve. Blood cultures were negative. Myocarditis and nonbacterial thrombotic endocarditis (NBTE) were diagnosed. As far as we know, NBTE is a rare manifestation of GPA and its presentation with myocarditis is not reported to date. This case indicates the uncommon manifestations of GPA and notifies the importance of performing echocardiography in order to prevent life threatening cardiac complications of the disease.