Nonbacterial Thrombotic Endocarditis Research Articles

Thrombectomy and Thrombolysis by Catheter Through Right Gastroepiploic Vein of Acute Superior Mesenteric Venous Thrombosis with Peritoneal Signs

Thrombectomy and Thrombolysis by Catheter Through Right Gastroepiploic Vein of Acute Superior Mesenteric Venous Thrombosis with Peritoneal Signs

Annals for Educators - 19 November 2019.

Annals for Educators - 19 November 2019.

Clinical Outcomes of Multiple Myeloma Patients Treated with Direct Oral Anticoagulants for Immunomodulatory Drug Associated Venous Thromboembolism

Introduction: Venous thromboembolism (VTE) is a common complication in multiple myeloma (MM) patients for several reasons; hematologic malignancy itself is a VTE risk factor and standard of care immunomodulatory drugs (IMiDs) in combination with dexamethasone (Dex) increase the risk further. This combination therapy has a mean VTE incidence of 21.5% in studies that did not use thromboprophylaxis and is recommended for all patients on IMiDs, although the optimal thromboprophylactic regimen remains uncertain. In clinical practice, aspirin (ASA) is commonly prescribed for VTE prophylaxis due to the ease of use. Despite this, the incidence of VTE remains between 7-14%. There is a growing body of literature supporting the efficacy and safety of direct oral anticoagulants (DOACs) for the treatment of VTE in cancer populations. We wanted to assess the incidence of VTE despite ASA prophylaxis at our institution and to further characterize the role of DOACs in the MM population. To do this, we performed a chart review of all MM patients who had been treated with lenalidomide and a DOAC, assessing for VTE development and patient outcomes. Methods: We conducted a retrospective chart review of patients with the diagnosis of MM treated with lenalidomide therapy at Fox Chase Cancer Center at Temple University Hospital or Cottman Avenue after Jan 1st, 2015 to July 2019. Eligible patients were identified through electronic medical record data mining for patients that had been diagnosed with MM, had been prescribed lenalidomide, had been taking ASA while on lenalidomide, and switched to rivaroxaban, edoxaban or apixaban. For comparison, the number of patients treated with lenalidomide and ASA who did not switch to a DOAC were also identified. Patient charts were reviewed for VTE development and bleeding complications after DOAC administration. Results: 132 patients were identified who had a diagnosis of MM and had been prescribed lenalidomide between Jan 1, 2015 and July 31, 2019. These patients were also prescribed aspirin except for three who were already on a DOAC prior to starting lenalidomide. Of the total 132 patients, only 17 were prescribed a DOAC. Six of the patients were on DOACs for reasons other than VTE (atrial fibrillation N=4, atrial flutter N=1, marantic endocarditis N=1). Eleven patients were started on DOACs for VTE; incidence of 8.3% in our myeloma population. However three of these VTEs occurred within one month of high dose melphalan chemotherapy and autologous stem cell rescue. These three patients had been off lenalidomide for over one month prior to VTE. Eight of the 17 patients with VTE developed clots in the setting of active MM and concurrent therapy with IMiD/Dex, independent of hospitalizations or other provoking factors. This is an incidence of 6.0% for VTE directly attributed to therapy. Six patients were on lenalidomide and Dex, while two patients developed VTE while on pomalidomide and Dex. No patients on lenalidomide experienced recurrent VTEs after being switched to therapeutic dose DOAC. One patient on pomalidomide/Dex did experience recurrent VTE. We examined all 17 patients who were on DOACs, 16 of which had been on IMiD and DOACs concurrently. Three had minor bleeding events which all resolved spontaneously. One patient had a major bleeding event, which was a fatal ruptured cerebral aneurysm while on a DOAC and ASA concurrently. Conclusion: The incidence of VTE in our patient population receiving IMiD/Dex while on ASA prophylaxis therapy was similar to what has been previously reported in the literature. We examined the clinical outcomes of 16 patients treated with IMiDs and DOACs concurrently and found few bleeding events. The one major bleed was likely precipitated by malignant hypertension and not a direct result of being on a DOAC. Taken together these results further support the growing body of evidence that DOACs are effective and safe treatments for VTE in cancer patients, including MM. Moving forward, our clinical experience with treatment dose DOACs supports the use of prophylactic dose DOACs to potentially further reduce the incidence of VTE in this high-risk population. Disclosures No relevant conflicts of interest to declare.

Small vessel multi-organ vasculitis and marantic endocarditis complicating rheumatoid arthritis.

Marantic endocarditis is an extremely rare extra-articular complication of rheumatoid arthritis. To date, documented cases typically occurred in the absence of other systemic features of disease activity. We report a rare and exceptional example of marantic endocarditis secondary to fulminant systemic rheumatoid vasculitis with multi-organ disease. Findings from this case and literature review suggest that marantic endocarditis associated with rheumatoid vasculitis displays a tendency to affect the mitral valve with high risk of embolization.

Marantic Endocarditis associated with Hodgkin's Lymphoma

La endocarditis trombotica no bacteriana (ETNB) se define como la presencia de trombos esteriles sobre las valvulas cardiacas, corresponden a agregados de plaquetas y fibrina no infectados asociados a estados de hipercoagulabilidad como las neoplasias malignas, en donde se denomina tambien endocarditis marantica. Se presenta el caso de un paciente con historia de sindrome febril prolongado al que se le inicio tratamiento antibiotico por una endocarditis infecciosa (EI) por presentar una imagen compatible con vegetacion en el ecocardiograma transtoracico. Sin embargo, el paciente persistio febril y sin mejoria clinica, hasta que la biopsia de un ganglio cervical diagnostico un linfoma de Hodgkin mejorando posteriormente con el tratamiento hemato especifico.

Antiphospholipid syndrome: a case report with an unusual wide spectrum of clinical manifestations

BackgroundAntiphospholipid syndrome (APS) is an autoimmune disease characterized by the occurrence of venous and/or arterial thrombosis, and the detection of circulating antiphospholipid antibodies. The classification criteria for definite APS are actually met when at least one clinical criterion (thrombosis or pregnancy morbidity) is present in association of one laboratory criterion (LAC, aCL antibody or aβ2GPI antibody present on two or more occasions, at least 12 weeks a part), and thrombosis should be confirmed by objective validated criteria. The average age of primary APS patients has been reported to be about 35–40 years and the disease is more common in women than in men.Case presentationIn this report, we described a rare case of an adult male who presented over a period of 9 years with a wide spectrum of clinical manifestations involving different organs that were not initially diagnosed as APS. Dizziness and syncope were his first clinical symptoms, and a non-bacterial thrombotic endocarditis (NBTE) involving the mitral valve was at first diagnosed. Subsequently, the patient also presented with generalized seizures and subsequent head injury. When the patient was admitted to our clinic with bilateral epistaxis and fever, thrombocytopenia was revealed. Moreover, laboratory examinations showed acute pancreatitis with an increase of levels of inflammation markers.ConclusionBased on the patient’s medical history and all the examination results, it was possible to make a diagnosis of primary APS and, starting from diagnosis of thrombocytopenia, we were allowed to conclude that all of manifestation were epi-phenomena of a unique clinical entity, rather than unrelated diseases. Though APS is one of the most common thrombocytophilias, unfortunately, it is not recognized often enough. The lack of prevention in undiagnosed patients may cause severe complications which can in turn result in the death of those patients.

CLOT ME IF YOU CAN: A CASE OF ANTIPHOSPHOLIPID ANTIBODY SYNDROME

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Non-bacterial thrombotic endocarditis (NBTE) is a disease characterized by the presence of vegetations on cardiac valves. NBTE has increasingly been recognized as a condition associated with numerous diseases and a potentially life-threatening source of thromboembolism. Antiphospholipid antibody syndrome (APS) is a systemic autoimmune disease defined by thrombotic or obstetrical events that occur in patients with persistent antiphospholipid antibodies. We present a case of NBTE who was found to have valvular regurgitation and thrombotic vegetations, an atypical manifestation of APS. CASE PRESENTATION: A 29 y/o female presented with substernal chest pain, fatigue and shortness of breath with exertion for 2 weeks duration. Review of system was negative. Vital signs were stable. Exam revealed crackles in lung bases, diastolic murmur heard along the left sternal border. She had no significant PMH. She smokes a pack of cigarettes every day. She denied any history of illicit drug use. CXR showed increased pulmonary vascular congestion in lung bases. Labs revealed elevated BNP (>7000). Echo showed normal LVEF, severe AR and moderate MR. TEE confirmed severe AR and severe MR with mass like vegetations and perforation of the aortic and mitral valve. Blood cultures were negative. Work up for culture negative bacterial endocarditis revealed positive antiphospholipid antibody profile with elevated Anti Beta-2 glycoprotein antibody as well as anti-cardiolipin antibody and positive lupus anticoagulant. Anti-smith Ab and anti-ds DNA Ab were negative. Further history revealed patient had 1 still birth and 3 pre-term deliveries, complicated by pre-eclampsia. Based on these findings patient was diagnosed with primary antiphospholipid antibody syndrome. Patient underwent aortic and mitral valve replacements. She clinically improved and was discharged home on coumadin. DISCUSSION: APS can occur either as a primary condition or in association with a systemic autoimmune condition like SLE. Patients can present with a broad spectrum of thrombotic and non thrombotic clinical manifestations. Diagnosis should be suspected when there is occurrence of one or more otherwise unexplained venous or arterial thrombotic events, especially in young patients. Clinical manifestations are thought to be secondary to the effects of antiphospholipid antibody on the pathways of anticoagulation. Our patient presented with atypical manifestations of APS with cardiac involvement and responded well to the valve surgery and anticoagulation. CONCLUSIONS: APS is a rare condition and clinicians should have a high index of suspicion in young patients presenting with thromboembolic manifestations or with signs of NBTE to prevent further life threatening complications. Reference #1: Giannakopoulos, B., and Krilis, S. A. (2013). The pathogenesis of the anti-phospholipid syndrome. N. Engl. J. Med. 368, 1033–1044. doi:10.1056 Reference #2: Crowther MA, Ginsberg JS, Julian J, Denburg J, Hirsh J, Douketis J, Laskin C, Fortin P, Anderson D, Kearon C, Clarke A, Geerts W, Forgie M, Green D, Costantini L, Yacura W, Wilson S, Gent M, Kovacs MJ. A comparison of two intensities of warfarin for the prevention of recurrent thrombosis in patients with the antiphospholipid antibody syndrome. N Engl J Med. 2003; 349: 1133–1138. Reference #3: Arnaud L Mathian A Devilliers Het al. Patient-level analysis of five international cohorts further confirms the efficacy of aspirin for the primary prevention of thrombosis in patients with antiphospholipid antibodies. Autoimmun Rev 2014; 14: 192–200. DISCLOSURES: No relevant relationships by Deepthi Gudivada, source=Web Response No relevant relationships by Venkat Rajasurya, source=Web Response

A RARE CASE OF CULTURE NEGATIVE WHIPPLE’S ENDOCARDITIS

SESSION TITLE: Cardiovascular Cases SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/22/2019 3:45 PM - 4:45 PM INTRODUCTION: Whipple’s disease is a rare opportunistic infection (1 out of 1,000,000). The classical presentation of Whipple’s disease involves joint arthropathy (migratory oligoarticular or polyarticular) and digestive disorders (diarrhea and weight loss). Cardiovascular disease involvement is noted about one third of the time (pericarditis, congestive heart failure [CHF], or rarely culture-negative endocarditis). This case highlights the importance of a high clinical index of suspicion for Tropheryma whipplei culture-negative endocarditis, in the setting of rheumatologic disease and abrupt worsening of cardiac function, without overt gastrointestinal symptoms. CASE PRESENTATION: An 84-year-old man with past medical history of prostate cancer, polymyalgia rheumatica (PMR), cryptogenic stroke, and mild mitral valve prolapse of posterior mitral valve leaflet was admitted for severe mitral insufficiency with recent acute CHF symptoms. Documented diagnosis of PMR occurred 18 months prior to acute CHF symptoms, for which the patient was treated with continuous, extensive prednisone taper, starting at 15 mg daily. Clinical presentation of acute CHF and transthoracic echocardiography showing myxomatous degeneration of posterior mitral leaflet, partially flail, with severe mitral regurgitation, prompted evaluation by cardiothoracic surgery. Patient underwent mitral valve repair and pathology was suggestive of nonbacterial thrombotic endocarditis with vegetative studding of mitral valve anterior leaflet. Serum polymerase chain reaction for T. whipplei was negative and the patient was initially treated with intravenous vancomycin and cefepime. Antibiotic regimen transitioned to intravenous ceftriaxone 2gm daily and ampicillin-sulbactam 3 gm every 6 hours for 6 weeks for seronegative endocarditis of unknown etiology. Genome sequencing of valvular tissue detected T. whipplei deoxyribonucleic acid (DNA) with 16s ribosomal ribonucleic acid (rRNA) gene primer set and Periodic acid-Schiff (PAS) staining was positive. This case of Whipple’s endocarditis is currently being treated with trimethoprim-sulfamethoxazole for an anticipated 12 months. DISCUSSION: This case illustrates the importance of considering T. whipplei as a causal agent of culture-negative endocarditis, especially in the presence of rheumatologic disease and absence of overt gastrointestinal symptoms. Furthermore, in cases of recently diagnosed rheumatologic disease with iatrogenic immunosuppression, risk factors for T. whipplei exposure should be evaluated. The limitations of serum polymerase chain reaction assay as a diagnostic tool for T. whipplei further supports a high suspicion should be maintained in culture-negative endocarditis. CONCLUSIONS: A history of culture-negative endocarditis, in the presence of recently diagnosed and treated rheumatologic disease, without gastrointestinal symptoms should raise suspicion for Whipple's Endocarditis. Reference #1: Fenollar, Florence, et al. “Whipples Disease.” New England Journal of Medicine, vol. 356, no. 1, 2007, pp. 55–66., https://doi.org/10.1056/nejmra062477. Reference #2: Alozie, Anthony, et al. “Arthralgia and Blood Culture-Negative Endocarditis in Middle Age Men Suggest Tropheryma Whipplei Infection: Report of Two Cases and Review of the Literature.” BMC Infectious Diseases, vol. 15, no. 1, 2015, https://doi.org/10.1186/s12879-015-1078-6. Reference #3: Gabus, Vincent, et al. “Tropheryma Whipplei Tricuspid Endocarditis: a Case Report and Review of the Literature.” Journal of Medical Case Reports, vol. 4, no. 1, 2010, https://doi.org/10.1186/1752-1947-4-245. DISCLOSURES: No relevant relationships by SIJAN BASNET, source=Web Response no disclosure on file for Ronald Herb; No relevant relationships by Abigayle Sullivan, source=Web Response No relevant relationships by Emily Zagorski, source=Web Response

Unicuspid aortic valve concomitant with aortic insufficiency presenting with infectious endocarditis: a case report

BackgroundA unicuspid aortic valve is a rare congenital cardiac abnormality. Despite its uncommon finding on an initial presentation, aortic insufficiency is accompanied with unicuspid aortic valve and this might reflect the natural history of progression in the morphology of unicuspid aortic valve.Case presentationWe describe a 65-year-old Japanese man who was evaluated for endocarditis and found to have a unicuspid aortic valve concomitant with moderate aortic insufficiency, which was, owing to the lack of evidence of valve membrane destruction, independent of underlying infectious endocarditis. In addition, aortic insufficiency was progressed because of nonbacterial thrombotic endocarditis on the ventricular side, in areas of high turbulence around the heart valve.ConclusionsOur case is unusual given the unicuspid aortic valve concomitant with aortic insufficiency, which was presumably independent of underlying infectious endocarditis because of the location of the vegetation and the lack of evidence of valve destruction. Therefore, attention should be paid to a variety of complications in the setting of unicuspid aortic valve.

Cancer and Cerebrovascular Disease.

To review the latest information about the interactions between cancer and cerebrovascular disease. Additional data support the finding that both ischemic and hemorrhagic stroke are important complications of cancer or its treatment. Reperfusion therapy is being given successfully to patients with stroke complicating cancer. Hemorrhagic stroke may occur with metastatic disease to the brain, coagulopathies from cancer, in particular leukemia, or as complications of chemotherapy. Ischemic stroke also may be a complication of metastatic disease with local invasion of vessels, a pro-thrombotic disorder such as non-bacterial thrombotic endocarditis (NBTE) or disseminated intravascular coagulation (DIC), or secondary to chemotherapy. Stroke also is a potential consequence of radiation therapy to the head and neck. Venous sinus thrombosis may develop with hematologic malignancies or chemotherapy. Although many patients will have a history of cancer at the time of stroke, a cerebrovascular event may be the initial manifestation of a malignancy.

Neurologic Complications of Infective Endocarditis: A Joint Model for a Septic Thromboembolism and Inflammatory Small Vessel Disease.

Embolic events from vegetations are commonly accepted as the main mechanism involved in neurologic complications of infective endocarditis. The pathophysiology may imply other phenomena, including vasculitis. We aimed to define the cerebral lesion spectrum in an infective endocarditis rat model. Experimental model of Staphylococcus aureus or Enterococcus faecalis infective endocarditis. Neurologic lesions observed in the infective endocarditis model were compared with three other conditions, namely bacteremia, nonbacterial thrombotic endocarditis, and healthy controls. Research laboratory of a university hospital. Male Wistar rats. Brain MRI, neuropathology, immunohistochemistry for astrocyte and microglia, and bacterial studies on brain tissue were used to characterize neurologic lesions. In the infective endocarditis group, MRI revealed at least one cerebral lesion in 12 of 23 rats (52%), including brain infarctions (n = 9/23, 39%) and cerebral microbleeds (n = 8/23, 35%). In the infective endocarditis group, neuropathology revealed brain infarctions (n = 12/23, 52%), microhemorrhages (n = 10/23, 44%), and inflammatory processes (i.e., cell infiltrates including abscesses, vasculitis, meningoencephalitis, and/or ependymitis; n = 11/23, 48%). In the bacteremia group, MRI studies were normal and neuropathology revealed only hemorrhages (n = 2/11, 18%). Neuropathologic patterns observed in the nonbacterial thrombotic endocarditis group were similar to those observed in the infective endocarditis group. Immunochemistry revealed higher microglial activation in the infective endocarditis group (n = 11/23, 48%), when compared with the bacteremia (n = 1/11, 9%; p = 0.03) and nonbacterial thrombotic endocarditis groups (n = 0/7, 0%; p = 0.02). This original model of infective endocarditis recapitulates the neurologic lesion spectrum observed in humans and suggests synergistic mechanisms involved, including thromboembolism and cerebral vasculitis, promoted by a systemic bacteremia-mediated inflammation.

Nonbacterial Thrombotic Endocarditis Due to Primary Gallbladder Malignancy with Recurrent Stroke Despite Anticoagulation: Case Report and Literature Review

Nonbacterial thrombotic endocarditis (NBTE) associated with malignancy is rare; its infrequency and similarity to other diagnoses make it a significant diagnostic challenge. A 63-year-old woman on rivaroxaban for prior deep vein thrombosis presented with left upper extremity weakness and left facial droop with imaging demonstrating multiple strokes. Echocardiograms revealed mitral and aortic valve vegetations. The patient was switched to apixaban and started on vancomycin and ceftriaxone for presumed culture-negative endocarditis. Despite continuing apixaban, her hospital course was complicated by new acute embolic infarcts. Workup confirmed non-mucinous metastatic biliary adenocarcinoma. The patient was placed on a heparin drip then switched to low molecular weight heparin without further embolic events and was discharged to a rehabilitation facility in stable condition with plans for chemotherapy as an outpatient. These clinical, imaging, and histologic findings were consistent with a rare case of NBTE associated with primary non-mucinous gallbladder malignancy complicated by recurrent strokes in which direct oral anticoagulants did not provide adequate anticoagulation.

Nonbacterial thrombotic endocarditis

An 83-year-old woman with a 10-year history of rheumatoid arthritis was admitted for urinary tract infection with exacerbation of chronic kidney disease and decompensated heart failure of unknown etiology. Transesophageal echocardiography (TEE) showed a vegetation involving the posterior mitral valve leaflet, and a hypothesis of infective endocarditis was proposed. Empirical antibiotic therapy was initiated. TEE was repeated after antibiotic therapy, and showed persistence of the original vegetation and revealed the presence of another, smaller vegetation. Clinical investigation revealed no infectious process, and so a diagnosis of nonbacterial thrombotic endocarditis (NBTE) was established. Anticoagulant therapy was started immediately. The NBTE lesion had disappeared on the follow-up echocardiogram two months after anticoagulant therapy.

A case of marantic endocarditis with systemic emboli in a patient with metastatic soft tissue sarcoma

Clinical manifestations of cancer can be categorized as resulting from direct tissue injury from the primary tumor, distant metastatic spread, or aberrant biological activity, also known as a paraneoplastic syndrome. Soft tissue sarcomas are a rare group of malignant tumors of mesenchymal origin which typically present with direct tissue injury, exerting their harmful potential by compression and mass effect. We describe a rare case of an occult retroperitoneal soft tissue sarcoma presenting with marantic endocarditis. To date, there is a paucity of available medical literature relating sarcoma to marantic endocarditis.

A Case of Nonbacterial Thrombotic Endocarditis with EGFR-mutated Lung Cancer Treated with Afatinib

A Case of Nonbacterial Thrombotic Endocarditis with EGFR-mutated Lung Cancer Treated with Afatinib

LIBMAN-SACKS ENDOCARDITIS IN A SYSTEMIC LUPUS ERYTHEMATOSUS MALE PATIENT

ABSTRACTPreliminary: Libman-Sacks endocarditis (verrucous vegetations, marantic, or nonbacterial thrombotic endocarditis) is a rare cardiac manifestation in SLE. The objective was to describe Libman-Sacks endocarditis in a SLE male patient.Case: A 21-year-old male was admitted to the hospital with shortness of breath, epigastric pain, oral ulcer, discoid lesions, and knee joints pain since 3 months before. He worked as a paper mill employee and was exposed to instruments radiating UV rays for 2 years. Antibiotics initiation was given due to an infective endocarditis suspicion. Vital signs were as follows: temperature 37oC, heart rate 110beats/minute, respiratory rate 30breaths/minute, blood pressure 100/80mmHg, and SaO2 99% with nasal oxygenation. Cardiac examination showed regular rate and rhythm with diastolic murmur at left ICS III and upper left sternal border. Lower extremities showed pitting edema. Laboratory results: hemoglobin 9.6g/dl, RBC 3.6x106/μl, hematocrit 30.8%, WBC 0.88x103/μl, platelet count 22x103/μl, BUN 74.0mg/dl, serum creatinine 1.6mg/dl, ESR 24mm/h, CRP 1.2mg/dl, C3 <16.4mg/dl, C4 8mg/dL, ANA test indeterminate (23.84), and anti dsDNA negative (7.4WHOunits/mL). Chest X-Ray showed mitral heart configuration with right ventricle and left atrium enlargement, pneumonia, and right pleural effusion. ECG showed normal sinus rhythm, left ventricular hypertrophy with repolarization abnormality, and prolonged QT wave. A 2-D echocardiogram showed an evidence of vegetation on aortic and pulmonary valve.Discussion: Based on the American College of Rheumatology SLE Criteria, low complement level, and evidence of vegetation on aortic and pulmonary valve, the patient was diagnosed as Libman-Sacks Endocarditis.Conclusion: The diagnosis should be confirmed by antiphospholipid antibodies examination.Key Words:

Cardiac MRI clinches diagnosis of Libman-Sacks endocarditis

A 28-year-old man presented to our hospital with exertional dyspnoea that had become gradually worse over the previous 3 months. On clinical examination of his heart, the apex was displaced laterally and inferiorly, the first heart sound was muffled, and there was a grade IV–VI apical pan-systolic murmur. 2 days after admission, the patient developed a non-haemorrhagic stroke. A transthoracic echocardiogram showed a dilated left ventricle with global hypokinesia and impaired systolic function: the left ventricular ejection fraction was 33% (video 1). A roughly spherical, relatively immobile mass, approximately 1·6 cm × 1·6 cm, was seen attached to the base of the posterior leaflet of the mitral valve (video 2). There was severe, eccentric, posteriorly directed mitral valve incompetence (video 1). A transoesophageal echocardiogram confirmed the transthoracic echocardiogram findings, but it did not help us understand the true nature of the mass (video 3). A three-dimensional transoesophageal echocardiogram confirmed the previous findings (appendix and video 3). All blood cultures obtained were negative. Additionally, we did a cardiac MRI to investigate the nature of the tissue or tissues of the abnormality. After confirming the location of the mass (video 3), the MRI showed an increased T2-weighted signal (figure) with an isointense T1-weighted signal. It also had an increased signal on delayed hyperenhancement (figure), with patchy myocardial fibrosis indicating myocarditis. Taken together, all these findings confirmed that the mass was not a thrombus or the vegetation of an infective endocarditis. We concluded the diagnosis was most likely to be non-infective endocarditis—commonly known as Libman-Sacks endocarditis. Laboratory investigations supported this diagnosis: a lupus anticoagulant test was positive and the levels of anticardiolipin IgM and anti-β2 glycoprotein I IgG antibodies—markers of the antiphospholipid syndrome—were increased. We started treatment with prednisone, an immunosuppressant (mycophenolate mofetil), anticoagulation, and measures to prevent cardiac failure. Pleasingly, the patient's clinical condition improved remarkably, and his left ventricular function increased with an ejection fraction of 43%; the mitral valve mass also reduced in size to 0·5 cm × 0·4 cm (figure and video 4).

Marantic or Non-Bacterial Thrombotic Endocarditis

Marantic endocarditis (MAE), “verrucous” or “Libman Sachs Endocarditis” are all different synonyms of the nowadays agreed term non-bacterial thrombotic endocarditis (NBTE), which is defined as fibrinous sterile valvular vegetations in the absence of infective endocarditis.

BIOPROSTHETIC AORTIC VALVE NONBACTERIAL THROMBOTIC ENDOCARDITIS WITHOUT UNDERLYING MALIGNANCY OR AUTOIMMUNE DISEASE

Prosthetic valve endocarditis is a recognized complication of valve replacement. Rarely, nonbacterial thrombotic endocarditis (NBTE) of a prosthetic valve has been described in patients with underlying malignancy or autoimmune disease. Thus far, there have been no published case reports of NBTE on a

Nonbacterial thrombotic endocarditis as the initial presentation of prostate cancer - a case report

Nonbacterial thrombotic endocarditis (NBTE) refers to noninfectious vegetations of the heart valves. It is commonly associated with malignancy and autoimmune diseases like systemic lupus erythematosus, Rheumatoid arthritis. Herein, we present Non-bacterial thrombotic endocarditis and Disseminated intravascular coagulation as the initial manifestations of prostate cancer. A 50-yearold gentleman, known case of hypertension and diabetes, presented with a history of recurrent ischaemic strokes, STEMI and a recent diagnosis of infective endocarditis. He had been taking antibiotics for the past 20 days without any improvement. Negative blood cultures in the presence of vegetations on repeat echocardiography led to a suspicion of NBTE. Laboratory investigations were suggestive of Disseminated intravascular coagulation. CT abdomen and pelvis demonstrated enlarged prostate with enlarged pelvic lymph nodes. Prostate specific antigen was raised at more than 100ng/ml. A bone scan showed extensive metastasis. The patient was started on GnRH analogue and bicalutamide. His Disseminated intravascular coagulation resolved and he was subsequently started on anticoagulants. The valvular lesions diminished without any residual dysfunction.