Nonbacterial Thrombotic Endocarditis Research Articles

Bronchogenic adenocarcinoma masquerading as recurrent embolic strokes and myocardial infarction due to nonbacterial thrombotic endocarditis

Bronchogenic adenocarcinoma masquerading as recurrent embolic strokes and myocardial infarction due to nonbacterial thrombotic endocarditis

An Unusual Cause of Transient Ischemic Attack

1Department of Cardiology, Royal Melbourne Hospital; 2Institute for Breathing and Sleep, Heidelberg; 3Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia Correspondence: Dr Liam Hannan, Institute for Breathing and Sleep, 145 Studley Road, Heidelberg, Melbourne, Victoria 3084, Australia. Telephone 778-8361863, e-mail liam.hannan@austin.org.au In April 2011, a 57-year-old woman with a long smoking history presented with transient symptoms of left-hand incoordination and dysarthria. At the time of arrival to hospital, there had been complete resolution of neurological signs and symptoms. Computed tomography and subsequent magnetic resonance imaging of the brain demonstrated no evidence of cerebral infarction and no other intracranial pathology. A routine chest radiograph revealed right middle lobe collapse. Computed tomography of the chest demonstrated a large proximal obstructing mass within the right middle lobe in addition to multiple bilateral pulmonary nodules suggestive of an advanced primary bronchogenic carcinoma with pulmonary metastases. There appeared to be tumour extension into the lateral wall of the left atrium (Figures 1A and 1B). Standard bronchoscopy demonstrated an endobronchial tumour at the origin of the right middle lobe bronchus, and endobronchial biopsy and brush cytology confirmed an adenocarcinoma that was TTF-1 and cytokeratin positive, consistent with a primary lung malignancy. A transesophageal echocardiogram demonstrated tumour infiltration of the right lower pulmonary vein with extension into the left atrium (Figure 2). There was no evidence of vegetations on the aortic or mitral valves, effectively excluding the possibility of marantic endocarditis. No other alternative sources of emboli were identified to explain the transient ischemic attack. With the exception of atrial myxoma, embolic phenomena due to intracardiac tumours are uncommon. Previous case reports of intracardiac extension of primary lung tumours have generally described extension via the pulmonary vein, as was apparent in the present case (1). The patient was referred for palliative radiotherapy for the primary lesion in addition to systemic chemotherapy. imAges in RespiRAtoRy medicine

Mitral Valve Surgery for Marantic Endocarditis and Multiple Cerebral Embolisation

Valvular involvement is common in antiphospholipid syndrome (APS) with increased risk of thrombo-embolic events. We report a patient with APS and multiple cerebral infarcts. Echocardiography demonstrated verrucous vegetations of the mitral valve in keeping with marantic endocarditis. The patient underwent successful mitral valve replacement. Post-operative clinical and echocardiographic follow-up showed excellent short term results.

Nonbacterial Thrombotic Endocarditis with ST-elevation Myocardial Infarction Treated with Percutaneous Coronary Aspiration Thrombectomy

ST-elevation myocardial infarction from coronary embolus is a rare complication of nonbacterial thrombotic endocarditis, with little data on therapeutic management. We present a novel use of percutaneous coronary aspiration thrombectomy using an Export(®) catheter resulting in successful restoration of normal coronary blood flow. We also demonstrated complete resolution of the thrombotic valvular lesion with double antiplatelet and anticoagulation therapy alone. The clinical manifestations and management of coronary embolisation from nonbacterial thrombotic endocarditis are reviewed.

Total palliative care for a patient with multiple cerebral infarctions that occurred repeatedly in association with gastric cancer (Trousseau's syndrome)

Malignancy-related thromboembolism, also referred to as Trousseau's syndrome, can present as acute cerebral infarction, nonbacterial thrombotic endocarditis (NBTE), and migratory thrombophlebitis. Therefore, many physical, neurological, and psychological symptoms associated with Trousseau's syndrome may occur in the clinical course. To illustrate this, we report a case of a male patient in his 50s with carcinomatous peritonitis caused by gastric cancer, with multiple cerebral infractions that developed during disease progression. The patient was admitted to our hospital for the treatment of side effects of chemotherapy, although he strongly hoped to go home as soon as possible. In addition to making social supports plans, we were required to perform intensive total palliative care, because of his physical pain, general fatigue, anorexia, abdominal and neck pain, and psychological issues (insomnia, delirium, depression, suicidal thoughts, self-mutilation, panic attacks, agoraphobia, fear of death, and feelings of hopelessness). To the best of our knowledge, based on the literature search, this is the first reported case of Trousseau's syndrome described in the context of total palliative care, especially psychological care. We propose that neurological symptoms of Trousseau's syndrome cause these extensive mental disorders. Furthermore, because of the prognosis of Trousseau's syndrome, we should utilize our expertise fulfill the patient's wishes.

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

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

An unusual case of pacemaker endocarditis in a patient with antiphospholipid syndrome

We report the case of a 50-year-old woman with systemic lupus erythematosus who had previously undergone pacemaker implantation. She developed recurrent pulmonary thromboembolism and was diagnosed with antiphospholipid syndrome. During investigation, pacemaker endocarditis was discovered, and the system was surgically explanted. Surprisingly, all microbiological studies, including culture of the extracted material and extensive serological analysis, were negative and she remained well with anticoagulation plus her usual immunosuppressant regimen.The data indicate that her pacemaker endocarditis could be an equivalent of the nonbacterial thrombotic endocarditis often described in native valves.

An unusual case of pacemaker endocarditis in a patient with antiphospholipid syndrome

We report the case of a 50-year-old woman with systemic lupus erythematosus who had previously undergone pacemaker implantation. She developed recurrent pulmonary thromboembolism and was diagnosed with antiphospholipid syndrome. During investigation, pacemaker endocarditis was discovered, and the system was surgically explanted. Surprisingly, all microbiological studies, including culture of the extracted material and extensive serological analysis, were negative and she remained well with anticoagulation plus her usual immunosuppressant regimen.The data indicate that her pacemaker endocarditis could be an equivalent of the nonbacterial thrombotic endocarditis often described in native valves.

Marantic endocarditis – A not so benign entity

Marantic, verrucous or nonbacterial thrombotic endocarditis, is characterised by the deposition of an amorphous mixture of fibrin and platelets onto heart valves. Although not commonly a cause of death in forensic practice, it may be associated with systemic embolisation. This was observed in a 60-year-old woman who suddenly collapsed and was found at autopsy to have a poorly differentiated adenocarcinoma of the lung with vegetations from marantic endocarditis on the mitral valve and embolisation with infarcts in the left kidney, the spleen, the right occipital cortex of the brain and the left ventricle of the heart. Death was due to coronary artery embolism from marantic endocarditis associated with an undiagnosed adenocarcinoma of the lung. Although marantic endocarditis is more common in hospital autopsies than in forensic cases, it can have lethal complications that result in sudden and unexpected death. Histories of debilitating disease and/or arterial thromboembolic episodes necessitate meticulous examination of the cardiac valves with careful serial sectioning of the major epicardial coronary arteries and histologic sampling of both ventricles.

Nonbacterial Thrombotic Endocarditis in a Child With Non-Hodgkin’s Lymphoma

The diagnosis of nonbacterial thrombotic endocarditis (NTBE) is rarely made during life. This report describes a child who had high-grade non-Hodgkin's lymphoma with NTBE and multiple systemic embolism. The transthoracic echocardiographic findings of mitral valve leaflet vegetations and progressive regurgitation led to surgical resection of the vegetations. A high index of suspicion is needed when a clinician is faced with a patient who has malignancy, systemic embolic phenomena, and persistent negative blood cultures.

Arterial Ischemic Stroke as a First Manifestation of Trousseau’s Syndrome

Malignancy related hypercoagulobility can manifest as acute arterial infarction, non-bacterial thrombotic endocarditis and thrombophlebitis. Rarely, ischemic stroke may be first symptom for a systemic occult cancer. We presented 62-year-old man who had recurrent stroke as the initial manifestation of an occult neoplastic process. Subsequently, the patient had venous thrombotic disease that led to the diagnosis of the malignancy. Conclusions: Acute or sub-acute multiple ischemic stroke may be the first manifestation of in an occult cancer.

巨大骨盤内腫瘍に合併した非細菌性血栓性心内膜炎の1例

巨大骨盤内腫瘍に合併した非細菌性血栓性心内膜炎の1例

Recurrent Embolic Stroke Due to Nonbacterial Thrombotic Endocarditis Followed by Transesophageal Echocardiography

Recurrent Embolic Stroke Due to Nonbacterial Thrombotic Endocarditis Followed by Transesophageal Echocardiography

Marantic Endocarditis in a Patient with Suspected Lung Cancer

63 year old man presented with left arm weakness, numbness and aphasia. Imaging of his head was done. MRI showed multiple strokes in cerebral cortex. CT head did not show any evidence of hemorrhage. He was evaluated by Neurology and was started on Heparin drip. Patient had another episode of stroke after a few hours. MRI head this time showed evolution of previously noted cerebral infarcts with small areas of hemorrhage and development of new bilateral cerebral and cerebellar infarcts. Heparin drip was discontinued. Further work up was done to evaluate the etiology of thromboembolism. Transesophageal Echocardiogram(TEE) showed small vegetations on the aortic and mitral valve. CT scans showed splenic and bilateral renal infarcts. Patient developed peripheral stigmata of endocarditis on the next day. Blood cultures were negative, so the empiric antibiotics were discontinued. His hospital course was complicated by development of Diffuse Alveolar Hemorrhage and DIC leading to his demise. He was suspected to have lung cancer due to weight loss, hemoptysis and suspicious lesion on CT scan of chest. Further work up including diagnostic bronchoscopy could not be done due to above complications and clinical deterioration. DIAGNOSIS

Stroke, Aortic Vegetations and Disseminated Adenocarcinoma – A Case of Marantic Endocarditis

Herein we describe a case of marantic endocarditis (non-bacterial thrombotic endocarditis) that presented with coronary, cerebral and peripheral emboli, fevers and malaise, and negative blood cultures. The 'kissing lesions' on all three leaflets of the aortic valve were bulky and friable. After aortic valve surgery, an acute abdomen prompted laparoscopy which demonstrated disseminated adenocarcinoma. We discuss the clinical presentation of this rare condition and the importance of considering marantic endocarditis secondary to malignancy as a differential diagnosis for culture negative endocarditis.

Non‐bacterial thrombotic endocarditis with systemic embolic events caused by adenomyosis

Non-bacterial thrombotic endocarditis is caused by a hypercoagulable state that is sometimes related to malignancy and this type of endocarditis associated with benign tumors has not yet been reported. In this study we report the first case of non-bacterial thrombotic endocarditis caused by adenomyosis, which is a benign gynecological condition.

Nonbacterial thrombotic endocarditis associated with cancer of unknown origin complicated with thrombus in the left auricular appendage: case report

A 63-year-old man was admitted to our hospital with a complaint of right lateroabdominal pain. He was diagnosed with metastatic colon cancer, and then developed multiple brain embolic infarctions 7 days after admission. Transesophageal echocardiography showed that mobile, echo-dense masses were attached to the anterior and posterior mitral valve leaflet. Furthermore, there was a thrombus in the left auricular appendage despite sinus rhythm. These findings led to a diagnosis of suspected infectious endocarditis with subsequent multiple brain infarctions. The patient's general condition worsened and he died 13 days after admission. An autopsy was performed, and, while poorly differentiated cancer was observed in multiple organs, no primary tumor could be identified. Histological analysis showed that the masses of the mitral valve consisted mainly of fibrin without bacteria or oncocytes. This patient was therefore diagnosed with nonbacterial thrombotic endocarditis associated with cancer of unknown origin complicated with thrombus in the left auricular appendage.

Primary hepatic neuroendocrine carcinoma with nonbacterial thrombotic endocarditis: A case report

Nonbacterial thrombotic endocarditis (NBTE) is occasionally found in patients with carcinoma (lung or gastrointestinal) or debilitating diseases. Definite diagnosis of NBTE should be performed by autopsy. It is difficult to diagnose NBTE if patients have no clinical signs of thromboembolism. Here, we present a case of primary hepatic neuroendocrine carcinoma with NBTE as proven by autopsy.

311 Nonbacterial thrombotic (Libman-Sacks) endocarditis with mitral regurgitation in catastrophic antiphospholipid syndrome (a case study)

Antiphospholipid syndrome (APS) is one of several prothrombotic states in which thrombi occur within both the venous and arterial beds. A minority of patients with APS present with an acute and devastating syndrome characterized by multiple simultaneous vascular occlusions throughout the body. “Catastrophic APS” is defined by the clinical involvement of at least three different organ systems over a period of days or weeks with histological evidence of multiple occlusions of large or small vessels. We report the case of a 16-year-old girl referred to our paediatric cardiology unit for NHYA IV and a blowing systolic murmur at the apex radiating to the left axilla. Transthoracic echocardiography (TTE) revealed mitral valve leaflet thickening with vegetations (13 mm) on the edges of both leaflets and moderate mitral regurgitation (MR) (image 1). The diagnosis of Libman-Sacks or non-bacterial thrombotic endocarditis secondary to antiphospholipid syndrome was suggested by repeated negative blood cultures along with persistently elevated anticardiolipin antibody titers. The condition deteriorated to acute thrombotic microangiopathy affecting multiple organs with arterial hypertension and thrombocytopenia. Anticoagulation with warfarin was peformed and aspirin, corticosteroids and ACE inhibitors were given. TTE follow-up after 1.5 years revealed no recurrence of MR with normal mitral valve leaflets. In catastrophic APS an aggressive therapeutic approach is warranted. Valve lesions may become more severe during long term follow-up.

Unusual Case of Nonbacterial Thrombotic Endocarditis Attributable to Primary Antiphospholipid Syndrome

A 54-year-old man was referred for cardiac evaluation before renal transplantation because of chronic renal failure. His medical history was remarkable for diabetes mellitus, hypertension, and 3 episodes of transient ischemic attack (the most recent was 3 years earlier). A transthoracic echocardiogram showed a large, mobile mass on the anterior leaflet of the mitral valve, with trivial mitral regurgitation (Figure 1; Movie I in the online-only Data Supplement). The mass was originally believed to be a fibroelastoma; endocarditis was not considered initially because of the absence of systemic symptoms. Transesophageal echocardiography showed a 1×2-cm mobile, echodense region on the A2 segment of the mitral valve leaflet (Figure 2 and Movie II in the online-only Data Supplement are 2-dimensional images; Figure 3 and …