Nonbacterial Thrombotic Endocarditis Research Articles

Multiple papillary fibroelastoma with quadricuspid aortic valve

had chronic rheumatoid arthritis; 9 patients (30%) had other underlying risk factors, such as congenital or degenerative heart valve disease or coagulation problem; and 3 patients (10%) had no risk factors. The majority of their patients underwent surgery for valve dysfunction. When patients can tolerate cardiac surgery with cardiopulmonary bypass, indications for surgery are valve dysfunction, recurrent embolic events, and mobile vegetation. Removal of vegetation and repair of the valve seem to be feasible if the vegetation is small and localized. Prognosis after valve replacement or repair for nonbacterial thrombotic endocarditis is unknown but depends on the underlying cause. Even if the previous femoropopliteal bypass was performed with the working diagnosis of Burger disease, it is unlikely because there was no arterial disease in the other leg. Because of the large size of the vegetation plus the possible delay of time between ischemic events, the patient’s limb ischemia was thought to be arterial embolization caused by the vegetation. His noncoronary aortic leaflet was atrophic, which may be a factor in causing nonbacterial thrombotic endocarditis. Despite the patient’s young age and good general condition, he should be monitored carefully for possible occult malignant disease.

An unusual case of nonbacterial thrombotic (marantic) endocarditis

An unusual case of nonbacterial thrombotic (marantic) endocarditis

Marantic Endocarditis and Disseminated Intravascular Coagulation With Systemic Emboli in Presentation of Pancreatic Cancer

Marantic Endocarditis and Disseminated Intravascular Coagulation With Systemic Emboli in Presentation of Pancreatic Cancer

Technetium 99m–Labeled Annexin V Scintigraphy of Platelet Activation in Vegetations of Experimental Endocarditis

The pathophysiology of infective endocarditis involves a pathogen/host tissue interaction, leading to formation of infected thrombotic vegetations. Annexin V is a ligand of phosphatidylserines exposed by activated platelets and apoptotic cells. Because vegetations are platelet-fibrin clots in which platelet proaggregant activity is enhanced by bacterial colonization, we investigated the ability of annexin V labeled with technetium Tc 99m (99mTc-ANX) to provide functional imaging of these vegetations in experimental models of infective endocarditis. This ability was assessed in rabbits and rats because of the different interest of these 2 species in preclinical analysis. Nonbacterial thrombotic endocarditis was induced with the use of a catheter left indwelling through the aortic or tricuspid valve, and animals were injected with either a bacterial inoculum or saline. Scintigraphic investigations were performed 5 days later and showed a higher 99mTc-ANX uptake by vegetations in infected versus noninfected animals (ratio, 1.3 for in vivo acquisitions and 2 for autoradiography; P<0.0001 for all), whereas no significant uptake was present in controls. Right-sided endocarditis was associated with pulmonary uptake foci corresponding to emboli. Histological analysis of vegetations showed a specific uptake of 99mTc-ANX at the interface between circulating blood and vegetation. In parallel, underlying myocardial tissue showed myocyte apoptosis and mucoid degeneration, without extracellular matrix degradation at this stage. 99mTc-ANX is suitable for functional imaging of platelet-fibrin vegetations in endocarditis, as well as embolic events. 99mTc-ANX uptake reflects mainly platelet activation in the luminal layer of vegetations. This uptake is enhanced by bacterial colonization.

A case of nonbacterial thrombotic endocarditis with difficult antemortem diagnosis

A case of nonbacterial thrombotic endocarditis with difficult antemortem diagnosis

Marantic endocarditis presenting as recurrent arterial embolisation

Marantic endocarditis is a non-infective cause of valvular masses. It is most commonly associated with advanced malignancy. We report a case of rapidly progressive marantic endocarditis, complicated by valve destruction and recurrent systemic embolisation, in a patient whose cancer was occult.

Nonbacterial thrombotic endocarditis associated with lung adenocarcinoma

Nonbacterial thrombotic endocarditis (NBTE) is a rather frequent neoplasic complication, most often occurring in adenocarcinomas of the lung and pancreas. The most frequent clinical manifestation is one of multiple cerebral infarcts, but other ischaemic events can occur. Diagnosis is frequently missed on transthoracic ultrasound, making transoesophagic ultrasound a more reliable diagnostic tool. We present a case of NBTE associated with lung adenocarcinoma.

Non-bacterial thrombotic endocarditis

Non-bacterial thrombotic endocarditis (NBTE) is a disease characterised by the presence of vegetations on cardiac valves, which consist of fibrin and platelet aggregates and devoid of inflammation or bacteria. NBTE has increasingly been recognised as a condition associated with numerous diseases and a potentially life-threatening source of thromboembolism. NBTE is not a common entity; however it is frequently underestimated, probably due to underlying diseases (cancer, autoimmune disorders, HIV). NBTE is difficult to diagnose and relies on strong clinical suspicion. NBTE is also difficult to manage and each case should be individually managed by identifying and treating the underlying pathology. Surgical intervention is not recommended unless the patient is in acute congestive failure.

Primitive neuroectodermal tumor of the myometrium with cardio-vascular symptoms

Background. Non-bacterial thrombotic endocarditis is a severe complication of cancer, rarely reported in gynecologic tumors. However, it can be inaugural and lead to complex diagnostic pathways. Case. A 40-year-old woman presented with a stroke, related to an endocarditis. The valvular vegetation was surgically removed, and a malignant node was resected. A PET-scan led to the diagnosis of a myometrial tumor, which was found to be a primitive neuroectodermal tumor (PNET). The patient underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy, and systemic chemotherapy which allowed a complete remission of tumoral and cardio-vascular symptoms. Conclusion. To our knowledge, this is the first case report of a PNET of the myometrium revealed by cardio-vascular symptoms.

Aortic valve replacement for aortic regurgitation in a patient with antiphospholipid antibody syndrome

Cardiac manifestations of antiphospholipid antibody syndrome (APLS) comprise a major complication. Herein we report our surgical treatment of aortic regurgitation in a patient with APLS. A 61-year-old woman was referred to our hospital with symptoms of congestive heart failure. Systemic lupus erythematosus had been diagnosed at the age of 36, and immunosuppressive therapy has been continuously performed. APLS was also diagnosed at the age of 55, after which cardiomegaly was noted on chest radiographs and aortic regurgitation was evident on echocardiography. Although immunosuppressive therapy had been continued, cardiac symptoms began to develop. With a presumed diagnosis of valvular disease associated with autoimmune disease, the aortic valve was replaced with a bioprosthesis. Noninfective endocarditis was confirmed in the excised specimen and was likely involved in APLS. The patient was discharged on postoperative day 26 without complications.

Nonbacterial Thrombotic Endocarditis in Cancer Patients: Pathogenesis, Diagnosis, and Treatment

Thrombophilia is a well-described consequence of cancer and its treatment. The pathogenesis of this phenomenon is complex and multifactorial. Nonbacterial thrombotic endocarditis (NBTE) is a serious and potentially underdiagnosed manifestation of this prothrombotic state that can cause substantial morbidity in affected patients, most notably recurrent or multiple ischemic cerebrovascular strokes. Diagnosis of NBTE requires a high degree of clinical suspicion as well as the judicious use of two-dimensional echocardiography to document the presence of valvular thrombi. In the absence of contraindications to therapy, treatment consists of systemic anticoagulation, which may ameliorate symptoms and prevent further thromboembolic episodes, as well as control of the underlying malignancy whenever possible.

Lung Cancer Masquerading as Prosthetic Valve Endocarditis

Although marantic endocarditis secondary to pulmonary adenocarcinoma is well described, it is very unusual for this symptom to be the initial presenting feature of lung cancer. Here we describe such a case in which marantic endocarditis affected not only the patient's native mitral valve, but also his newly implanted bioprosthetic valve--a phenomenon that has not been previously reported.

Quadrivalvular marantic endocarditis (ME) mimicking acute bacterial endocarditis (ABE)

Marantic endocarditis (ME) is defined by noninfectious valvular vegetations. The most common disorders associated with ME are malignancy with or without hypercoagulable state, intercardiac instrumentation, residual vegetations from previously treated infective endocarditis (IE), renal insufficiency, and burns. Another important cause of ME is systemic lupus erythematosus when accompanied by vegetations, that is, Libman-Sacks endocarditis. ME should be differentiated from IE because they may present with similar clinical features. Both ME and IE may present with fever and a heart murmur with or without embolic phenomenon. Leukocytosis and elevated erythrocyte sedimentation rate suggest the diagnosis of IE. The hallmark of IE is a cardiac vegetation and continuous high-grade bacteremia. After exclusion of the causes of culture negative endocarditis, the absence of bacteremia clearly differentiates ME from IE. We present a case of ME mimicking acute bacterial endocarditis (ABE). The differential diagnostic features of ME versus IE are discussed. To the best of our knowledge, this is the first reported case of quadrivalvular ME with massive vegetations on all cardiac valves, as well as the aorta, atria, and pulmonary artery.

Marantic endocarditis (NBTE) with systemic emboli and paraneoplastic cerebellar degeneration: uncommon presentation of ovarian cancer

We report a case in which the only presenting symptoms of the underlying ovarian malignancy were that of paraneoplastic cerebellar degeneration and nonbacterial thrombotic endocarditis. If suspecting paraneoplastic cerebellar degeneration and nonbacterial thrombotic endocarditis, complete physical examination, including pelvic exams in female patients is warranted. Investigations should include CT chest/abdominal/pelvis, MRI brain, and Transesophageal Echocardiogram. Early recognition will lead to early diagnosis of occult malignancy and initiation of appropriate therapy. Awareness of these complications as initial presentation for internists, gynecologists and neurologists may avoid diagnostic delay.

Nonbacterial Thrombotic Endocarditis: Clinicopathologic Study of a Necropsy Series

Nonbacterial thrombotic endocarditis (NBTE) is characterized by sterile platelet and fibrin deposition on cardiac valves. In this study, our aim was to investigate the clinicopathologic characteristics of patients diagnosed with NBTE at the 12 de Octubre University Hospital in Madrid, Spain. Patients were identified by analyzing reports of autopsies carried out at the Anatomical Pathology Department of the University Hospital between 1974 and 1977 and between 1980 and 2004. Out of 2041 autopsies, 22 (1.08%) showed evidence of NBTE. The patients' average age was 63.04 years, and neither sex predominated. The underlying disease was an infection in 54.5% of cases, whereas 31.8% had a neoplasm, most frequently a pancreatic adenocarcinoma or renal carcinoma. In 10 cases, there was a previous valvulopathy. The mitral valve was most frequently affected by NBTE (36.5% of cases). In most cases, the cause of death was the underlying disease, though in two patients it was directly related to NBTE (9.1%). In nine cases, an embolism occurred, principally in the spleen, the kidneys or the central nervous system. Before death, there was no suspicion of NBTE in any of these cases. NBTE is an uncommon disease entity that occurs not only in patients with end-stage neoplastic disease, but also in those with potentially treatable diseases. Consequently, we should raise our level of awareness of this condition so that a diagnosis can be made before the patient dies and anticoagulant treatment can be started, thereby helping to improve prognosis.

Cancer, thrombosis and heparin-induced thrombocytopenia

Venous thromboembolism (VTE) is a common occurrence in patients with cancer, and can sometimes precede the development of the clinical manifestations of cancer. The pathogenetic mechanisms of thrombosis involve a complex interaction between tumour cells and the host haemostatic system, in addition to cancer-related clinical risk factors. The risk of VTE increases in presence of distant metastases. The development of VTE in patients with cancer is a strong predictor of decreased survival. The most common medical situations that make cancer patients at a higher risk of VTE include immobilization and chemotherapy with or without adjuvant hormone therapy. Recent findings suggest that heparin-induced thrombocytopenia (HIT) and HIT-related thrombotic complications may occur in cancer patients with a higher frequency than in patients free from malignancy. Thromboembolism is a well-recognised complication of malignant disease. Clinical manifestations vary from venous thromboembolism (VTE) to disseminated intravascular coagulation, more commonly observed in patients with haematological malignancies and those with widespread metastatic cancer, to arterial embolism, more commonly observed in patients undergoing chemotherapy and in those with non-bacterial thrombotic endocarditis.

Nonbacterial thrombotic endocarditis with recurrent embolic events as manifestation of ovarian neoplasm

Nonbacterial thrombotic endocarditis with recurrent embolic events as manifestation of ovarian neoplasm

Unexplained choroidal embolisation: remember the antiphospholipid syndrome

In January, 2005, a 58-year-old woman presented complaining of bilateral sudden painless loss of vision, followed by perception of fl oaters. She had a history of colon carcinoma 2 years previously, and had been diseasefree since her treatment. Her visual acuity was 20/100 in the right eye and 20/40 in the left. Fundus examination showed scattered multiple choroidal infarcts bilaterally in the posterior pole surrounding the macular area (fi gure A). A 2+ vitreal fl are was also seen bilaterally. Fluorescein angiography showed hypofl uoresence at the infarcted sites in early stages and hyperfl uoresence at the late stages. Physical examination showed only a grade 2/6 systolic murmur of the heart. Two-dimensional transoesophageal echocardiography showed mobile vegetations of the mitral valve. Extensive laboratory blood tests, including tumour markers, C-reactive protein, fi brinogen, rheumatoid factor, antinuclear antibodies, anti-double-stranded DNA antibodies, antineutrophil cytoplasmic antibodies, and C3 and C4 complement components, showed only a mild prolongation of activated partial thromboplastin time (37 s). Serological tests for bacterial and viral infections were negative. Long-duration incubation of blood and aqueoushumour cultures were negative. Abdominal ultrasonography, CT of the chest and abdomen, brain MRI, carotid doppler tests, and colonoscopy showed no abnormalities. Further testing gave a positive result for IgG anticardiolipin antibodies (IgG-aCL), with a binding index of 370 (index cut-off =100, which corresponds to the cut-off of 15–20 GPL units of the commercially available assays) on a highly sensitive, specifi c, and inter nationally accepted ELISA. She was also positive for IgM-aCL and lupus anticoagulant (ratio: 1·65; normal <1·2) by the diluted Russell’s viper venom test (HemosIL, Instrumentation Laboratory Company, Lexington, MA, USA). The IgG-aCL titre remained positive 6 weeks and 12 weeks after the fi rst test (binding index 456 and 379, respectively, which correspond to more than 80 GPL units with the conventional assays). Antiphospholipid syndrome (APS) accom panied by non-bacterial thrombotic endocarditis was considered, and anticoagulant treatment with acenocoumarol was started with target INR 3·0–3·5. After 4 weeks, her visual acuity had improved (right eye 20/50; left eye 20/25). Vitreal fl are disappeared 6 weeks after presentation. 8 weeks after her intitial presentation, transoesophageal echocardiography and cardiac MRI showed no abnormalities. At a 5-month follow-up appoint ment, her visual acuity had improved further (right eye 20/25; left eye 20/20). 1 year after her initial presentation, the patient’s fundus (fi gure B), visual acuity, and general health have remained stable. When last seen in May, 2006, she remained well. APS is an autoimmune disorder characterised by arterial or venous thrombosis, recurrent fetal loss, and circulating antiphospholipid antibodies. It has been implicated in a range of ocular disorders. The clinical features of ocular involvement seem to be diff erent in primary and secondary APS—vasculopathic eye disease involving retinal and choroidal vessels seems to be typical in the primary form, whereas retinal thrombosis is more common in APS associated with systemic lupus erythematosus. In our patient, APS was the main mechanism leading to choroidal infarction. Non-bacterial thrombotic endocarditis can accompany malignant disorders whether or not they are associated with APS. In our case, we were not able to detect a relapse of cancer, which is in accordance with a prospective study showing high aCL titres in some cancer patients even during clinical remission of the disease. These associations suggest the need for thorough followup for thrombotic events in aCL-positive cancer. Additionally, unexplained ocular manifestations should alert physicians for APS presence because the ophthalmological symptoms can be the fi rst clinically evident manifestations of this disorder, and anticoagulant treatment should be started as soon as possible.

Recurrent strokes in a 46-year-old woman: rapidly progressive nonbacterial thrombotic endocarditis

The Case: A 46-year-old nurse was admitted to the Neurology Department after 6 weeks of recurrent and transient neurologic episodes. She described several episodes of disorientation, language abnormalities and motor weakness, all resolving within an hour. She thought the episodes likely related to

Endocarditis trombótica no bacteriana y neoplasia pulmonar

A woman with the final diagnosis of non-bacterial thrombotic endocarditis associated to pulmonary adenocarcinoma is reported. She had had repetitive embolic strokes as the first manifestation, with vegetations on the mitral valve and without signs of acute infectious disease. The case is interesting because is an usually case of nonbacterial thrombotic endocarditis and the importance of an early diagnostic.