Nonbacterial Thrombotic Endocarditis Research Articles

ODP451 A Case of Papillary Thyroid Cancer Presenting with Marantic Endocarditis and Recurrent Stroke

Abstract Marantic endocarditis or non-bacterial thrombotic endocarditis (NBTE) is characterized by the presence of vegetations on cardiac valves, which consist of fibrin and platelet aggregates and are devoid of inflammation or bacteria. The hypercoagulable state associated with malignancy is well known to be associated with NBTE. Here we report a rare case of Papillary Thyroid Cancer presenting with Marantic Endocarditis and Recurrent Stroke. A 52-year-old lady, with medical background of hypertension, presented to the Emergency Department with history of sudden onset of difficulty in speaking for 3 days. On examination she had slurred speech and tongue deviation to the right side. Neurological examination was otherwise normal. Imaging revealed left frontal, right frontal and left cerebellar infarcts. Transthoracic Echocardiogram showed a large, highly mobile vegetation 18 mm in size, attached to the posterior mitral valve leaflet as well as severe Mitral Regurgitation. She was diagnosed as a case of Cardioembolic ischemic stroke due to endocarditis. She completed a course of empiric antibiotic therapy. However, her blood cultures and fungal culture revealed no growth. After 5 years, she again presented to the hospital with acute stroke. Trans esophageal Echocardiography now revealed multiple filamentous vegetations on the atrial surface of mitral valve, largest measuring 20 mm×4 mm. Her inflammatory markers were negative and 3 sets of blood cultures were again negative. A question was raised, as to whether the filamentous masses represent prolapsing ruptured chordae tendinae rather than vegetations. FDG PET-CT scan was thus performed and revealed: Left thyroid lobe focal uptake seen with an FDG-avid left parajugular lymph node. Ultrasound neck was then performed, which showed bilateral thyroid nodules with high suspicion ultrasound pattern per American Thyroid Association: ill-defined nodule seen in the lower pole measuring 8×8×7 mm with multiple foci of macrocalcification. Thyroid function tests were normal. Ultrasound guided thyroid fine needle aspiration (FNA) biopsy of the left thyroid nodule was performed. The cytology report was consistent with papillary thyroid carcinoma. She is planned for total thyroidectomy, after undergoing mitral valve replacement surgery. This case illustrates one of the paraneoplastic syndromes associated with thyroid cancer. A hypercoagulable state has been observed in several types of thyroid cancer, although the pathogenesis has not been well studied. The etiology of cancer-associated coagulopathy is complex, related to an imbalance in the hemostatic system and abnormal levels of coagulation factors. Further studies on the occurrence of thrombosis in different types of thyroid cancer would help to inform clinical practice in the management of thyroid cancer, including the need for anticoagulation in certain situations. Presentation: No date and time listed

A New Insight Into Nonbacterial Thrombotic Endocarditis: A Systematic Review of Cases.

Nonbacterial thrombotic endocarditis is characterized by the presence of organized thrombi on cardiac valves, often associated with hypercoagulable states. There is a paucity of data regarding the predictors of mortality in patients with nonbacterial thrombotic endocarditis. Our primary aim was to identify predictors of in-hospital mortality in patients with nonbacterial thrombotic endocarditis. A systematic literature review of all published cases and case series was performed until May 2018 according to Preferred Reporting Items for Systematic Review and Meta-analyses statement guidelines. We applied random forest machine learning model to identify predictors of in-patient mortality in patients with nonbacterial thrombotic endocarditis. Our search generated a total of 163 patients (mean age, 46 ± 17 years; women, 69%) with newly diagnosed nonbacterial thrombotic endocarditis. The in-hospital mortality rate in the study cohort was 30%. Among the patients who died in the hospital, initial presentation of pulmonary embolism (12.2 vs. 2.6%), splenic (38.7 vs. 10.5%), and renal (40.8 vs. 9.6%) infarcts were higher compared to patients alive at the time of discharge. Higher rates of malignancy (71.4 vs. 39.4%, P = .0003) and lower rates of antiphospholipid syndrome (8.1 vs. 48.2%, P = .0001) were noted in deceased patients. Random forest machine learning analysis showed that older age, presence of antiphospholipid syndrome, splenic infarct, renal infarct, peripheral thromboembolism, pulmonary embolism, myocardial infarction, and mitral valve regurgitation were significantly associated with increased risk of in-hospital mortality. Patients admitted with nonbacterial thrombotic endocarditis have a high rate of in-hospital mortality. Factors including older age, presence of antiphospholipid syndrome, splenic/renal infarct, lower limb thromboembolism, pulmonary embolism, myocardial infarction, and mitral valve regurgitation were significantly associated with increased risk of in-hospital mortality in patients with nonbacterial thrombotic endocarditis.

Marantic endocarditis and cancer: diagnosis, treatment and outcomes: a multicentric cohort study

Abstract Background Marantic endocarditis (ME) associated with cancer is a rare disease with a poor prognosis. Unlike infective endocarditis (IE), whose diagnosis and therapeutic management are based on strong evidence, ME management solely relies on clinical cases, autopsies and literature reviews of descriptive articles. Purpose To describe clinical characteristics, management therapies and outcome of patients presenting with ME associated with cancer. To assess the role of multimodal imaging in the diagnosis of this disease. Methods In a retrospective multicentric study including four tertiary centers for treatment of endocarditis in France and Belgium, patients with a diagnosis of ME were included. Demographic, imaging (echocardiography, PET-CT, computed tomography) and management data were collected. Long-term mortality was analyzed. Results Between November 2011 and August 2021, 47 patients with a diagnosis of ME were included. Mean age was 65±11 years. ME occurred in 43 cases (91%) on native valves. 89% (42 patients) were left-sided ME and the most common cardiac valve involved were aortic (34 cases, 73%) and mitral (26 cases, 55%). Systemic embolism was frequent (40 patients, 85% of cases). One year mortality was 55% (26 patients). 22 patients (46%) had a known cancer before ME and 25 cases (54%) were diagnosed thanks to paraclinical investigations. Most cancers were lung (19 cases, 40%) following by pancreatic cancers (10 cases, 20%). PET CT was performed in 30 patients (64%) and allowed a new diagnosis of cancer in 14 patients (30%). 41 patients (88%) were treated medically with anticoagulation therapy. 6 patients (12%) underwent valve surgery. Conclusion To our knowledge, our study included the largest cohort of patients presenting with ME. The prognosis of ME is poor due to its association with advanced malignancy and related to the frequency of thromboembolic events. Diagnosis of ME is challenging and multimodal imaging, especially PET CT seems to be very useful to distinguish IE and ME by revealing cancers. Funding Acknowledgement Type of funding sources: None.

The marantic kiss: potential novel pathognomonic echocardiographic sign of non-bacterial thrombotic endocarditis.

The marantic kiss: potential novel pathognomonic echocardiographic sign of non-bacterial thrombotic endocarditis.

Nonbacterial Thrombotic Endocarditis Progressed Aortic Stenosis of a Bicuspid Aortic Valve in a Patient With Advanced Cancer

Nonbacterial Thrombotic Endocarditis Progressed Aortic Stenosis of a Bicuspid Aortic Valve in a Patient With Advanced Cancer

Polycythemia Vera leading to Jaundice and Marantic Endocarditis, A Case Presentation

Polycythemia vera is an uncommon myeloproliferative neoplasm characterized by the abnormal proliferation and maturation of hematopoietic stem or progenitor cells. It is also known as one of the BCR-ABL1 negative myeloproliferative neoplasms, along with essential thrombocythemia and myelofibrosis. Incomparison to essential thrombocythemia and myelofibrosis, polycythemia is driven by JAK2 mutations, specifically JAK2V617F, an activating mutation encoding a tyrosine kinase [1]. This variant mutation is correlated with increased erythropoiesis and myelopoiesis, lower platelet count, higher incidence of splenomegaly, pruritus and thrombotic events. A 58-year-old male presented to the Emergency Department complaining of pruritus and painless jaundice. Comprehensive blood count revealed an elevated white blood cell count, hemoglobin/ hematocrit, and platelets. Total bilirubin was elevated at 30.3g/dL, with a direct bilirubin of 27g/dL. A Jak- 2 mutation was positive, which suggested a diagnosis of polycythemia vera although atypical given his jaundice. An Erythropoietin level was found to be less than 1, suggesting a primary cause of polycythemia vera. In addition, the patient was found to have marantic nonbacterial thrombotic endocarditis on transesophageal echocardiogram. Patient was treated with aspirin to prevent thrombotic events, hydroxyurea and cholestyramine. The patient’s physical examination of profuse jaundice along with an elevated direct bilirubin count of 27g/dL typically does not correlate to a presentation of polycythemia vera. Through further workup, the patient did not demonstrate hemolytic or intrahepatic causes, both intrinsic and extrinsic to the liver, which would of explained the jaundice presentation. This led to a conclusion that the patient’s polycythemia vera most likely caused the jaundice presentation.

Clinical case of an ischemic stroke of the patient with non-bacterial thrombotic endocarditis

Ischemic stroke in oncological diseases occurs as a result of the prothrombotic effect caused by cancer. Besides that, it is associated with antitumor therapy. In the first instance, cardioembolism should be ruled out for recurrent systemic embolism in patients with a tumor history. In most cases, the cause of cerebral embolism in oncological diseases is non-bacterial thrombotic endocarditis. Its diagnosis preferably based on transesophageal echocardiography. This article presents a clinical case of ischemic stroke developed by marantic endocarditis, methods of its verification and treatment.

A Case of Non-Bacterial Thrombotic Endocarditis with Atypical Massive Vegitation

A Case of Non-Bacterial Thrombotic Endocarditis with Atypical Massive Vegitation

Causes of ischemic stroke in young adults versus non-young adults: A multicenter hospital-based observational study.

BackgroundVery few comparative studies have focused on the differences in the causes of ischemic stroke between young adults and non-young adults. This study was performed to determine what causes of ischemic stroke are more important in young adults than in non-young adults using a large-scale multicenter hospital-based stroke registry in Fukuoka, Japan.Methods and resultsWe investigated data on 15,860 consecutive patients aged ≥18 years with acute ischemic stroke (mean age: 73.5 ± 12.4 years, 58.2% men) who were hospitalized between 2007 and 2019. In total, 779 patients were categorized as young adults (≤50 years of age). Although vascular risk factors, including hypertension, diabetes mellitus, and dyslipidemia, were less frequent in young adults than in non-young adults, the prevalence of diabetes mellitus and dyslipidemia in young adults aged >40 years were comparable to those of non-young adults. Lifestyle-related risk factors such as smoking, drinking, and obesity were more frequent in young adults than in non-young adults. As young adults became older, the proportions of cardioembolism and stroke of other determined etiologies decreased, but those of large-artery atherosclerosis and small-vessel occlusion increased. Some embolic sources (high-risk sources: arterial myxoma, dilated cardiomyopathy, and intracardiac thrombus; medium-risk sources: atrial septal defect, nonbacterial thrombotic endocarditis, patent foramen ovale, and left ventricular hypokinesis) and uncommon causes (vascular diseases: reversible cerebral vasoconstriction syndrome, moyamoya disease, other vascular causes, arterial dissection, and cerebral venous thrombosis; hematologic diseases: antiphospholipid syndrome and protein S deficiency) were more prevalent in young adults than in non-young adults, and these trends decreased with age.ConclusionsCertain embolic sources and uncommon causes may be etiologically important causes of ischemic stroke in young adults. However, the contribution of conventional vascular risk factors and lifestyle-related risk factors is not negligible with advancing age, even in young adults.

Pancreatic cancer with multiple liver metastasis complicating multi-organ infarcts from marantic endocarditis and Trousseau's syndrome

A middle-aged previously healthy and fit man presented with left sided weakness, slurred speech, left sided sensory neglect, mild headache and fever. He denied having any cough, shortness of breath, chest pain, palpitations, abdominal pain or bowel-bladder symptoms. He has smoked 5–10 cigarettes

Extensive Vegetation on the Mitral Valve Due to Non-Bacterial Thrombotic Endocarditis.

Extensive Vegetation on the Mitral Valve Due to Non-Bacterial Thrombotic Endocarditis.

A MOBILE MASS ON THE AORTIC VALVE

TYPE: Late Breaking Case Report TOPIC: Cardiovascular Disease INTRODUCTION: Marantic endocarditis, also called Nonbacterial Thrombotic Endocarditis (NBTE), is a condition immune mediated condition that signifies noninfectious lesions or vegetations to the endocardium. CASE PRESENTATION: 68-year-old female with past medical history of homozygous MTHFR C677T mutation with normal homocysteine, spontaneous deep vein thrombosis and pulmonary embolism, status post IVC filter on anticoagulation therapy was seen for evaluation of tachycardia. She is found to have atrial fibrillation with rapid ventricular response of 148 bpm. Transthoracic echocardiogram (TTE) and subsequent trans-esophageal echo (TEE) showed large vegetation (15mmx12mm) with mobile components on the aortic valve and severe aortic insufficiency (AI). The patient remained afebrile throughout the evaluation and had several negative blood cultures without antibiotics. Laboratory values showed no elevation in white blood cell count and mild elevation in erythrocyte sedimentation rate and C-reactive protein. Patient was evaluated for surgical intervention and was found having extensive periodontitis which required extraction of her lower jaw teeth. The patient eventually had a successful surgical aortic valve replacement. The final pathology revealed a dystrophic calcifications, some neutrophils and abundant fibrin deposition but no bacteria on specimen culture. DISCUSSION: Murantic endocarditis does not frequently present with fever, and was an incidental finding in this case. The relatively rare neutrophils seen within the thrombotic vegetation by pathology sample were felt to represent entrapped peripheral blood elements rather than evidence of a host inflammatory response. CONCLUSIONS: Overall, the features are favored to represent NBTE, a conclusion supported by the patient's serially negative blood cultures and negative tissue cultures on the valve specimen. DISCLOSURE: Nothing to declare. KEYWORD: Vegitations,Murantic endocarditis, thrombotic, aortic valve

COVID19 INFECTION AND LIBMAN –SACKS ENDOCARDITIS IN PAST VALVE REPAIRED PATIENT

Objective: The patient was a 61-year-old woman who typically underwent mitral valve replacement and tricuspid valve repair in 2011. During these years, she underwent an annual checkup and experienced no particular problems. The potential patient contracted Covid 19 a month ago and underwent conservative treatment. The patient displayed no specific symptoms, no fever, and her Covid 19 disease was mild. In the accompanying echocardiography, we notice a lump on the atrial surface of the Tricuspid valve that we instantly suspect of local vegetation or heart mass. As a result, we admitted the patient to resume the examination. Design and method: Multi-slice (16) spiral thoracic CT scan: Sternotomy and MVR are seen. Cardiomegaly is evident. Patchy peripheral ground-glass opacities are seen bilaterally, suggesting covid-19 pneumonia; correlation with clinical and paraclinical data is recommended. Degenerative changes are perceived in the thoracic spine. There is no pleural effusion. Blood cultures and urinary trachea were requested to diagnose endocarditis, and she was also asked to have an esophageal echocardiogram. The antibiotic Meropenem 500 was started three times a day with vancomycin 1 gram twice a day for prophylaxis. After these examinations, the mass diagnosis was rejected as the image of vegetation on echocardiography did not found echogenicity similar to cardiac tissue and was denser. Consequently, we diagnosed vegetation. According to the negative culture results, and the patient had no symptoms (chills, heart pain), this patient’s diagnosis of an immunological reaction caused by Covid disease was made. Libman –sacks endocarditis is a type of sterile nonbacterial thrombotic endocarditis (NBTE) secondary to inflammation. Results: In this rare case, the vital point is that immunological reaction after covid can give rise to vegetation on the heart artificial valve and can be typically established with endocarditis. Covid can cause libman sac endocarditis, then we consider patients with heart disease maybe get limban sac or other forms of immunological reaction after covid virus. Conclusions: Concerning the explicit rejection of all the causes, the patient was diagnosed correctly with limb sac endocarditis. She underwent anticoagulant therapy and corticosteroid therapy accordingly and was recovered fully.

Contemporary demographics, diagnostics and outcomes in non-bacterial thrombotic endocarditis

ObjectiveNon-bacterial thrombotic endocarditis (NBTE) is a syndrome characterised by cardiac valve vegetations and/or thickening due to non-infective mechanisms. Nowadays, a premortem diagnosis of NBTE is possible based on echocardiographic findings....

Infective and nonbacterial thrombotic endocarditis in patients with post-COVID-19 viral-immune myocarditis

The possibility of heart inflammation (both myocardial and endocardial) months after a coronavirus disease 2019 (COVID-19) has not been practically studied, especially since approaches to the treatment of myocarditis in combination with various endocarditis forms have not been developed.Aim. To study the prevalence and mechanisms of SARS-CoV-2-associated endocardial injury in patients with morphologically verified post-COVID-19 myocarditis, as well as to develop approaches to comprehensive therapy.Material and methods. The study included 18 patients with severe morphologically verified post-COVID-19 myocarditis (men, 9; 51,1±9,4 years; 35 to 66 years). Patients with prior verified myocarditis/myocardial infarction, rheumatic heart disease, and systemic immune diseases were excluded. The average time after COVID-19 was 6,5 [3.5; 10] months The diagnosis of myocarditis was confirmed by endomyocardial biopsy (including immunohistochemical examination with antibodies to CD3, CD20, CD45, CD68, and to SARS-CoV-2 antigens; polymerase chain reaction for SARS-CoV-2 RNA, DNA of cardiotropic viruses). The blood level of anticardiac antibodies was determined by indirect immunofluorescence. In addition, echocardiography, magnetic resonance imaging (n=8), cardiac multislice tomography (n=1), and coronary angiography (n=14) were performed.Results. Biopsy revealed active (n=12) and borderline (n=3) lymphocytic myocarditis, eosinophilic (n=2) and giant cell (n=1) myocarditis. In 4 patients, nonbacterial thrombotic endocarditis (NBTE) with parietal and intravascular thrombosis was diagnosed, and in one patient — infective endocarditis (IE) of the bicuspid aortic valve. Myocardial persistence of SARS-CoV-2 was detected in 72% of cases (in 3 patients — with NBTE; in 1 — with IE; in 9 — without endocarditis). Titers of anticardiac antibodies increased by 3-4 times in 94% of patients. Patients with endocarditis were characterized by larger heart chambers, lower ejection fraction (27,5±6,6 vs 36,0±13,4%), more severe pulmonary hypertension, and valvular regurgitation. Intraventricular thrombosis according to echocardiography/magnetic resonance imaging and cardiac embolism was not observed. Treatment in all patients included methylprednisolone at an average dose of 24 mg a day. In 10 patients, the result was monitored for at least 3 months as follows: the ejection fraction was 46,0±12,7% and 44,3±7,3% in patients with and without endocarditis, respectively.Conclusion. Endocarditis in patients with post-COVID-19 myocarditis was detected in 28% (1 patient — IE; 4 — NBTE). The key mechanisms of post-COVID-19 myocarditis and NBTE are long-term (up to 18 months) myocardial persistence of SARS-Cov-2 and the development of an autoimmune reaction. Endocarditis was diagnosed in more severe patients, including those with giant cell and eosinophilic myocarditis. The effectiveness of steroid therapy in combination with anticoagulants in patients with NBTE requires further study. In case of IE, steroids can also be used in the treatment of myocarditis (in combination with antibiotics and immunoglobulin).

Cancer-associated non-bacterial thrombotic endocarditis

This paper reviews the current evidence on the pathogenesis, clinical manifestations, diagnosis and management of cancer-associated non-bacterial thrombotic endocarditis (NBTE). NBTE is an underdiagnosed condition characterized by sterile valvular vegetations composed of platelets and fibrin which are susceptible to systemic embolization. Cancer is a leading cause of NBTE and should be excluded in NBTE cases without a clear etiology. Malignancies most frequently associated with NBTE are mucin-releasing adenocarcinomas of the lung, ovary, biliary system, pancreas, breast and stomach. NBTE carries a high risk of arterial thromboembolism, while cardiac valvular dysfunction is much less frequent. NBTE appears to be an important underdiagnosed cause of cancer-associated embolic stroke of undetermined source. Characteristics associated with cancer-associated NBTE include elevated D-dimer, visceral infarcts, cerebral infarcts in multiple vascular territories, transcranial doppler microembolic signals, disseminated cancer and adenocarcinoma histology. Transesophageal echocardiography is the diagnostic test of choice, and all suspected cases should be evaluated for the presence of elevated D-dimers and disseminated intravascular coagulation. Long-term anticoagulation with low molecular weight heparin should be strongly considered, and surgical intervention is usually not needed. Underlying cancer must be diagnosed swiftly (if previously undiagnosed) and anti-cancer treatment should be initiated as soon as possible. The paucity of data regarding all aspects of NBTE, and the severe clinical consequences of untreated NBTE, are an urgent call for future research.

Polymorphisms of candidate genes determining the clinical and hemostasiological characteristics of endocarditis of various etiology

Aim. To investigate polymorphisms of 18 genes as possible molecular genetic markers of predisposition or resistance to development of non-infective (NE) or infective endocarditis (IE).Materials and methods. The study encompassed 81 patients with NE and 94 patients with IE. The control group included 225 conditionally healthy people. Polymorphisms of 18 genes were tested using polymerase chain reaction (PCR).Results. For the first time, a statistically significant relationship was identified between gene polymorphisms and valvular vegetations: for genes in the hemostatic system – rs6025 (1691 G > A) of the F5 gene (AG genotype), rs1126643 (807 C > T) of the ITGA2 gene (TT genotype); for folate pathway genes – rs1805087 (2756 A > G) of the MTR gene (AG genotype) and rs11697325 (–8202 A/G) of the MMP9 gene (AA genotype) and rs2476601 (C1858T) of the PTPN22 gene (TT genotype). The protective effect of gene polymorphisms was revealed: for the NOS3 gene (4b / 4b genotype) and G (–572) C of the IL6 gene (CC genotype). For two polymorphisms, an association with thromboembolic complications in NE was revealed: rs1126643 (807 C > T) of the ITGA2 gene and rs1799889 (–675 5G > 4G) of the PAI (SERPINE1) gene. In IE, such an association was detected for the polymorphism rs11697325 (–8202 A/G) of the MMP-9 gene.Conclusion. The polymorphisms of candidate genes were revealed, that are associated with the clinical and hemostasiological characteristics of IE and NE. In NE, for the first time, the association with thromboembolic complications was identified for two polymorphisms: rs1126643 (807 C > T) of the ITGA2 gene and rs1799889 (– 675 5G > 4G) of the PAI-1 (SERPINE1) gene. In IE, such a relationship was detected for one polymorphism – rs11697325 (8202 A/G) of the MMP-9 gene.

Nonbacterial Thrombotic Endocarditis: Presentation, Pathophysiology, Diagnosis and Management

Initially described in 1936, non-bacterial thrombotic endocarditis (NBTE) is a rare entity involving sterile vegetations on cardiac valves. These vegetations are usually small and friable, typically associated with hypercoagulable states of malignancy and inflammatory diseases such as systemic lupus erythematosus. Diagnosis remains challenging and is commonly made post-mortem although standard clinical methods such as echocardiography (transthoracic and transesophageal) and magnetic resonance imaging may yield the clinical diagnosis. Prognosis of NBTE is poor with very high morbidity and mortality usually related to the serious underlying conditions and high rates of systemic embolization. Therapeutic anticoagulation with unfractionated heparin has been described as useful for short term prevention of recurrent embolic events in patients with NBTE but there are no guidelines for management of this disease.

IgG4-Related Disease Masquerading as Culture-Negative Endocarditis

We detail an extremely rare case of noninfective endocarditis secondary to IgG4-related disease on the mitral valve. A 75-year-old-woman with mitral valve ring annuloplasty presented with subacute, intermittent, self-limiting neurologic deficits. Magnetic resonance imaging of her brain revealed multiple small infarcts consistent with a cardioembolic phenomenon. Transesophageal echocardiogram revealed mobile, strand-like vegetations. She was taken for surgical repair of her mitral valve and tissue biopsy confirmed the diagnosis of IgG4-related disease. Our knowledge of this rare disease is continuously evolving, and this case highlights an exceptionally rare manifestation of this poorly understood disease.

Hemophagocytic Lymphohistiocytosis Associated With Endocarditis: A Case Years in the Making.

Hemophagocytic Lymphohistiocytosis Associated With Endocarditis: A Case Years in the Making.