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Tisch C, Ernst D, Falke M, Speicher P, Ziaka M. Systemic embolization due to non-bacterial thrombotic endocarditis: An autopsy case report and mini review of the literature. SAGE Open Med Case Rep 2024; 12:2050313X241229576. [PMID: 38292877 PMCID: PMC10826374 DOI: 10.1177/2050313x241229576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/12/2024] [Indexed: 02/01/2024] Open
Abstract
Nonbacterial thrombotic endocarditis is a rare, non-infectious complication associated with hypercoagulable states, such as malignancies and autoimmune diseases. Due to the difficulty distinguishing marantic endocarditis from infective endocarditis, the diagnosis is often delayed or even a postmortem finding. We present the case of a 70-year-old Caucasian female with marantic endocarditis secondary to metastatic duodenal adenocarcinoma. The patient presented with a short history of memory deficits, personality disturbances, and left homonymous hemianopia. Diffusion-weighted magnetic resonance imaging showed multi-territorial bihemispheric cerebral infarctions. Transthoracic echocardiography revealed native mitral valve endocarditis, and serial blood cultures remained negative. Despite antibiotic therapy, the patient's condition continuously deteriorated, and she died within 3 weeks after her initial presentation. Postmortem examination showed a non-bacterial thrombotic endocarditis. Early clinical suspicion and prompt diagnosis are of decisive importance for the survival of the patients.
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Affiliation(s)
- Carmen Tisch
- Department of Internal Medicine, Hospital of Thun, Thun, Switzerland
| | - Daniel Ernst
- Department of Internal Medicine, Hospital of Thun, Thun, Switzerland
| | - Monika Falke
- University of Bern, Institute of Tissue Medicine and Pathology, Bern, Switzerland
| | - Philip Speicher
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mairi Ziaka
- Department of Internal Medicine, Hospital of Thun, Thun, Switzerland
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Rua CR, Laranjeira MR, Dionisio AC, Mendes MA, Martins LR. Unveiling Lung Adenocarcinoma: Non-bacterial Thrombotic Endocarditis as the Debut Sign. Cureus 2023; 15:e45271. [PMID: 37846253 PMCID: PMC10576842 DOI: 10.7759/cureus.45271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2023] [Indexed: 10/18/2023] Open
Abstract
Non-bacterial thrombotic endocarditis (NBTE) involves the deposition of fibrin and platelets on heart valves, frequently leading to systemic embolism. The association between NBTE and cancer demands thorough investigation in cases lacking an evident cause. This case report elucidates the clinical course of a nonsmoking woman in her sixties with NBTE linked to pulmonary adenocarcinoma. The patient, who had a history of multiple sclerosis (MS) and was receiving dimethyl fumarate treatment, presented to the emergency department with stroke-like symptoms. Diagnostic challenges arose due to preexisting motor sensory impairment from MS. Initial evaluations revealed hypocapnia and elevated inflammatory markers. Blood cultures were obtained twice, and imaging confirmed pneumonia, left pleural effusion, and chronic pulmonary embolism while excluding acute vascular events or intracranial hemorrhage. The first transthoracic echocardiogram (TTE) indicated no cardiac abnormalities. Treatment encompassed parenteral antibiotics, systemic anticoagulation, and admission to medical floors. Although the initial treatment yielded a positive clinical response, subsequent complications emerged. On the tenth day, the patient required additional interventions, including broad-spectrum antibiotics and supplemental oxygen. A follow-up chest X-ray revealed persistent pneumonia and pleural effusion, and blood cultures upon admission returned negative. A subsequent head MRI confirmed an embolic stroke and displayed evidence of MS progression. Around the twentieth day, empirical treatment for infective endocarditis was initiated, and an 8 mm vegetation on the aortic valve was identified via transesophageal echocardiography (TOE). Acute pulmonary edema prompted a transfer to the intermediate care unit. Further investigations, including left thoracocentesis and CT, unveiled exudate and metastatic lesions in the liver, ilium, and kidney. Unfortunately, on the twenty-fifth day, the patient experienced acute myocardial infarction, right leg ischemia, disseminated intravascular coagulation, and shock. Pleural fluid analysis revealed malignant cells suggestive of lung adenocarcinoma. This case underscores the pivotal role of timely NBTE recognition and the search for malignancy when workup for infective endocarditis and autoimmune panels is negative. Moreover, it emphasizes the significance of vigilant monitoring, particularly in immunocompromised individuals or those with preexisting neurological deficits, especially when new neurological symptoms manifest. These insights significantly contribute to the comprehension of NBTE management and its implications for analogous patient cohorts.
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Affiliation(s)
- Catarina R Rua
- Rheumatology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Mariana R Laranjeira
- Internal Medicine, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Ana C Dionisio
- Internal Medicine, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Maria A Mendes
- Allergy and Immunology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
| | - Lourenco R Martins
- Radiology, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, PRT
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Brubaker HA, Sooklal DH. Recurrent Thromboembolic Events While on Anticoagulation Lead to the Diagnosis of Metastatic Lung Adenocarcinoma: A Case Report. Cureus 2023; 15:e37827. [PMID: 37213972 PMCID: PMC10197990 DOI: 10.7759/cureus.37827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/23/2023] Open
Abstract
Lung cancer can lead to hypercoagulability that causes thromboembolic events such as pulmonary emboli, deep vein thrombosis, ischemic strokes, and non-bacterial thrombotic endocarditis. While it is not uncommon for cancer to cause thromboembolic events, it is unusual for thrombotic events to be the first manifestation of cancer. In the following report, we review the case of a 59-year-old woman who presented with melena and abdominal pain. She had a pertinent history of multiple thromboembolisms while on anticoagulation four months before this presentation. Upon admission, it was discovered that the patient had new pulmonary emboli, and further workup revealed that her gastrointestinal symptoms were due to ischemic colitis. While initial imaging showed no evident masses that would heighten suspicion of cancer, she had persistent abdominal lymphadenopathy. Therefore, she also underwent an abdominal lymph node biopsy which revealed metastatic lung adenocarcinoma, a possible cause of her hypercoagulable state. This case report highlights the importance of considering malignancy in the differential of a patient with recurrent thromboembolism and raises the question of whether standardized screening for malignancy in patients with multiple thromboembolic events would be beneficial.
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Affiliation(s)
- Heather A Brubaker
- Internal Medicine, Edward Via College of Osteopathic Medicine, Blacksburg, USA
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Rahouma M, Khairallah S, Dabsha A, Elkharbotly IAMH, Baudo M, Ismail A, Korani OM, Hossny M, Dimagli A, Girardi LN, Mick SL, Gaudino M. Lung Cancer as a Leading Cause among Paraneoplastic Non-Bacterial Thrombotic Endocarditis: A Meta-Analysis of Individual Patients' Data. Cancers (Basel) 2023; 15:cancers15061848. [PMID: 36980734 PMCID: PMC10047261 DOI: 10.3390/cancers15061848] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/04/2023] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
Hypercoagulability is strongly associated with cancer and may result in non-bacterial thrombotic endocarditis (NBTE). The aim of our meta-analysis was to explore the demographics and characteristics of this condition in cancer. Databases were systematically searched. The outcomes were to identify the annual trend in premortem diagnosis among the entire cohort and different subgroups and to identify differences in characteristics and survival in the considered population. A total of 121 studies with 144 patients were included. The proportion of marantic endocarditis associated with lung cancer was 0.29 (95% CI, 0.21-0.37; p < 0.001), that associated with pancreatic cancer was 0.19 (95% CI, 0.13-0.27; p < 0.001), that associated with advanced cancer stage (metastasis) was 0.69 (95% CI, 0.61-0.76; p < 0.001), and that associated with adenocarcinoma was 0.65 (95% CI, 0.56-0.72; p < 0.001). Median and 6-month overall survival (OS) were 1.3 months and 32.3%, respectively, with 6-month OS of 20.8% vs. 37.0% in lung vs. other cancers, respectively (p = 0.06) and 42.9% vs. 31.1% among those who underwent intervention vs. those who did not (p = 0.07). Cases discovered in recent years had better survival (HR = 0.98 (95% CI, 0.96-0.99; p = 0.003). While cancer-associated NBTE is a rare entity, lung cancers were the most common tumor site and are frequently associated with more advanced and metastatic cancer stages. The prognosis is dismal, especially among lung cancers.
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Affiliation(s)
- Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 12613, Egypt
| | - Sherif Khairallah
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 12613, Egypt
| | - Anas Dabsha
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 12613, Egypt
| | - Ismail A M H Elkharbotly
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 12613, Egypt
- General Surgery Department, Newham University Hospital, London E13 8SL, UK
| | - Massimo Baudo
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
- Department of Cardiac Surgery, Spedali Civili di Brescia, 25123 Brescia, Italy
| | - Amr Ismail
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 12613, Egypt
| | - Omnia M Korani
- Department of Medical Oncology, National Cancer Institute, Cairo University, Cairo 12613, Egypt
| | - Mohamed Hossny
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
| | - Stephanie L Mick
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
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Harris AZ, Ternouth I, Lallu BD. Case report: marantic endocarditis in renal cell carcinoma: nephrectomy a treatment. Eur Heart J Case Rep 2021; 5:ytab437. [PMID: 34859186 PMCID: PMC8633635 DOI: 10.1093/ehjcr/ytab437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/13/2021] [Accepted: 10/19/2021] [Indexed: 11/14/2022]
Abstract
Background Marantic endocarditis (non-bacterial thrombotic endocarditis) is a rare condition that involves non-infectious thrombotic lesions typically of the aortic and mitral valves. It is predominantly associated with malignancy and less commonly systemic lupus erythematosus. In this case, we report a patient with marantic endocarditis secondary to a renal cell carcinoma that was successfully treated with nephrectomy and anticoagulation. Case summary A 65-year-old male patient with embolic signs and symptoms was found to have non-infective thrombotic vegetations on three cardiac valves through transoesophageal echocardiography. Computed tomography revealed a 70 mm renal mass that confirmed to be a grade two clear-cell renal cell carcinoma. Nephrectomy and anticoagulation led to resolution of the embolic symptoms and of the valvular vegetations. Discussion The diagnosis of marantic endocarditis requires high clinical suspicion in a patient who presents with features of embolization. Incidence is highest in patients with an underlying malignancy, particularly adenocarcinoma. This case highlights the importance of echocardiography in diagnosis, removal of the source of thrombus, and prompt treatment with anticoagulation.
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Affiliation(s)
- Andrew Z Harris
- Taranaki Base Hospital, Taranaki District Health Board, David Street, Westown, New Plymouth 4310, New Zealand
| | - Ian Ternouth
- Taranaki Base Hospital, Taranaki District Health Board, David Street, Westown, New Plymouth 4310, New Zealand
| | - Bhavesh D Lallu
- Taranaki Base Hospital, Taranaki District Health Board, David Street, Westown, New Plymouth 4310, New Zealand
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Zmaili MA, Alzubi JM, Kocyigit D, Bansal A, Samra GS, Grimm RA, Griffin BP, Xu B. The Reply. Am J Med 2021; 134:e468. [PMID: 34340756 DOI: 10.1016/j.amjmed.2021.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 04/09/2021] [Indexed: 10/20/2022]
Affiliation(s)
| | - Jafar M Alzubi
- Department of Medicine, Cleveland Clinic Akron General, Akron, Ohio
| | - Duygu Kocyigit
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Agam Bansal
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio
| | | | - Richard A Grimm
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian P Griffin
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bo Xu
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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