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Yazidi MA, Merzouk FZ, Rabii H, Benyoussef H, Bensahi I, Habbal R. Ischemic Stroke Revealing Libman-Sacks Endocarditis: A Case Report. J Saudi Heart Assoc 2023; 35:335-338. [PMID: 38116400 PMCID: PMC10727131 DOI: 10.37616/2212-5043.1360] [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: 10/05/2023] [Revised: 11/01/2023] [Accepted: 11/10/2023] [Indexed: 12/21/2023] Open
Abstract
Libman-Sacks endocarditis (LSE) is a characteristic but rare feature of systemic lupus erythematosus (SLE), which can be found in association with antiphospholipid syndrome (APS), exposing the patient to an increased embolism risk, particularly the occurrence of ischemic stroke. We present a case involving a 64-year-old man who was admitted for ischemic stroke accompanied by a fever. Cardiac investigation revealed mitral vegetations along with severe mitral regurgitation. The diagnosis of Libman-Sacks endocarditis associated with SLE and APS was made after a laboratory work-up showing negative blood cultures and positive antibodies. This case underlines the importance of early diagnosis for better management of this pathology.
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Affiliation(s)
- Malak A. Yazidi
- Cardiology Department of Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca,
Morocco
| | - Fatima Z. Merzouk
- Cardiology Department of Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca,
Morocco
| | - Hajar Rabii
- Cardiology Department of Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca,
Morocco
| | - Hicham Benyoussef
- Cardiovascular Surgery Department of Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca,
Morocco
| | - Ilham Bensahi
- Cardiology Department of Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca,
Morocco
| | - Rachida Habbal
- Cardiology Department of Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca,
Morocco
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Svantner J, Lavanchy L, Labouchère A. Recurrent embolic strokes due to antiphospholipid syndrome and non-bacterial thrombotic endocarditis in a patient with basal cell carcinoma. J Cardiothorac Surg 2023; 18:177. [PMID: 37170311 PMCID: PMC10176810 DOI: 10.1186/s13019-023-02266-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 04/03/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Non-Bacterial Thrombotic Endocarditis (NBTE) is a common form of aseptic thrombotic endocarditis that primarily affects mitral valves and less frequently aortic valves. NBTE is caused by systemic inflammatory reactions. This condition induces valve thickening or attached sterile mobile vegetation. NBTE is mostly asymptomatic; however, major clinical manifestations result from systemic emboli rather than valve dysfunction. When significant damage occurs, valvular insufficiency or stenosis can appear and promote heart failure occasionally requiring valve replacement surgery. NBTE is associated with hypercoagulable states, systemic lupus erythematous (SLE), antiphospholipid syndrome, or malignancies. CASE PRESENTATION We report successful biological aortic valve replacement surgery including cardiopulmonary bypass for a 78-year-old man with NBTE and voluminous vegetation on the aortic valve inducing moderate aortic insufficiency and acute heart failure. The histopathological analysis of the valve sample showed myxoid degeneration, fibrous remodeling, and partial necrosis without any bacteria, thus indicating marantic endocarditis. Initially, the patient presented to the emergency department with an acute stroke. He was already using Apixaban treatment for a history of atrial fibrillation and cardioembolic stroke. Because of the recurrence of stroke and appearance of aortic vegetation, the investigations were extended. The antiphospholipid antibodies were positive without any indication of bacterial endocarditis. The malignancy screening was positive for basal cell carcinoma (BCC). The surgery and postoperative course were uneventful, and the patient was discharged with vitamin K antagonists (VKA). To our knowledge, NBTE with such a volume is rare and its apparent association with BCC has not been previously reported. CONCLUSION Outside of SLE and antiphospholipid syndrome, NBTE is a rare and underdiagnosed disease associated with thromboembolic events. Adequate anticoagulation is a cornerstone of its treatment. Anticoagulation management during perioperative care and valve surgery deserves specific attention and helps to protect the patient from embolic complications. In the case of stroke and thromboembolic events of unclear cause or suspected NBTE, echocardiography and thrombophilia assessments including an immunological workup are recommended.
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Affiliation(s)
- Julianna Svantner
- Department of Intensive Care, Hospital of Valais, Sion, Switzerland.
- Department of Anesthesiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
| | - Luc Lavanchy
- Department of Anesthesiology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ania Labouchère
- Department of Intensive Care, Hospital of Valais, Sion, Switzerland
- Department of Plastic and Hand Surgery, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Basnet S, Stauffer T, Jayswal A, Tharu B. Recurrent nonbacterial thrombotic endocarditis and stroke on anticoagulation. J Community Hosp Intern Med Perspect 2020; 10:466-469. [PMID: 33235685 PMCID: PMC7671729 DOI: 10.1080/20009666.2020.1791028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
We present a rare case of recurrent nonbacterial thrombotic endocarditis (NBTE) and stroke despite anticoagulation. A 48-year-old man with history of antiphospholipid syndrome, prior nonbacterial aortic valve endocarditis status post valve replacement and prior stroke was found to have acute ischemic stroke while on apixaban and nonbacterial thrombotic endocarditis of mitral valve. This was initially managed conservatively with therapeutic dose of enoxaparin, but the patient later underwent mitral valve replacement. Unfortunately, the patient later passed away with hemorrhagic stroke while on enoxaparin.
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Affiliation(s)
- Sijan Basnet
- Department of Internal Medicine, Reading Hospital and Medical Center, West Reading, PA, USA
| | - Thomas Stauffer
- Department of Emergency Medicine, Reading Hospital and Medical Center, West Reading, PA, USA
| | - Amar Jayswal
- Department of Medicine, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Biswaraj Tharu
- Department of Medicine, Trumbull Regional Medical Center, Warren, OH, USA
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Premyodhin N, Glovaci D, Azam S, Chou R, Barseghian A. Distinguishing aortic valve thrombus from Libman-Sacks endocarditis in antiphospholipid syndrome: imaging and management. Future Cardiol 2020; 17:101-111. [PMID: 32648500 DOI: 10.2217/fca-2020-0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aortic valve (AV) thrombus, a rare complication of antiphospholipid syndrome (APLS), is important to distinguish from Libman-Sacks endocarditis because of its responsiveness to anticoagulation. This may be attributed to immunopathologic differences underpinning their development. We present the case of a 45-year-old woman with high-risk primary APLS who developed an AV mass and was taken for valvular repair surgery but found to have pure thrombus and normal valve leaflets. In such cases, a trial of conservative management with anticoagulation may be adequate. Echocardiography, computed tomography and MRI findings suggestive of thrombus without endocarditis are presented. A literature review of histopathologic, imaging and treatment implications of pure AV thrombus in the context of APLS is included.
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Affiliation(s)
- Ned Premyodhin
- Department of Medicine, Division of Cardiology, University of California, Irvine School of Medicine, 333 City Boulevard West, Suite 400, Orange, CA 92868, USA
| | - Diana Glovaci
- Department of Medicine, Division of Cardiology, University of California, Irvine School of Medicine, 333 City Boulevard West, Suite 400, Orange, CA 92868, USA
| | - Sarah Azam
- Department of Medicine, Division of Cardiology, University of California, Irvine School of Medicine, 333 City Boulevard West, Suite 400, Orange, CA 92868, USA
| | - Raymond Chou
- Department of Surgery, Division of Cardiothoracic Surgery, University of California, Irvine School of Medicine, 101 The City Drive South, Building Number 53, Room Number 117, Orange, CA 92868, USA
| | - Ailin Barseghian
- Department of Medicine, Division of Cardiology, University of California, Irvine School of Medicine, 333 City Boulevard West, Suite 400, Orange, CA 92868, USA
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Zaman S, Rahim MA, Sayami LA, Nabi S, Islam AM, Ullah M. Libman-Sacks endocarditis in a Bangladeshi patient suffering from rhupus. Trop Doct 2019; 49:309-311. [PMID: 31180802 DOI: 10.1177/0049475519854623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Libman-Sacks endocarditis (LSE) is one of the most characteristic cardiac lesions in systemic lupus erythematosus (SLE). Patients may remain asymptomatic, while symptomatic patients often suffer with systemic emboli. These commonly test positive for anti-phospholipid antibody (aPA). The association of LSE with an overlap of rheumatoid arthritis (RA) and lupus (also known as 'rhupus') is rare. We report such a patient, who had been diagnosed as having RA seven years before and had suffered an acute ischaemic stroke one year previously and had echocardiographic evidence of LSE found during routine evaluation. However, she tested negative for aPA.
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Affiliation(s)
- Shahana Zaman
- Junior Consultant, Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh
| | - Muhammad Abdur Rahim
- Associate Professor, Department of Nephrology, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital, Dhaka, Bangladesh
| | - Lima Asrin Sayami
- Junior Consultant, Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh
| | - Shaila Nabi
- Associate Professor, Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh
| | - Akm Monwarul Islam
- Associate Professor, Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh
| | - Mohammad Ullah
- Associate Professor, Department of Cardiology, Colonel Malek Medical College, Manikgonj, Bangladesh
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Sun LL, Tang WX, Tian M, Zhang L, Liu ZJ. Clinical Manifestations and Mechanisms of Autoimmune Disease-Related Multiple Cerebral Infarcts. Cell Transplant 2019; 28:1045-1052. [PMID: 31062611 PMCID: PMC6728708 DOI: 10.1177/0963689719846838] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
It is important to investigate the clinical characteristics and identify the stroke
mechanisms of patients with autoimmune disease-related stroke, which are necessary for
early etiology diagnosis, accurate treatment and preventive strategies. In this article we
retrospectively studied eight cases of acute ischemic stroke associated with autoimmune
diseases, and without competing conventional stroke etiologies. The characteristics of
stroke (clinical and radiological features), the laboratory tests especially serum D-dimer
levels (as a marker of hypercoagulable state), and embolic signals on transcranial Doppler
were evaluated for all eight patients. High-resolution magnetic resonance imaging (HRMRI),
which can help to evaluate vasculitis was performed in four patients. The possible
underlying mechanisms of these cases were discussed based on these manifestations. As a
result, autoimmune diseases in our study included systemic lupus erythematosus
(n=5), mixed connective tissue disease (n=1), central
nervous system vasculitis (n=1), and Takayasu arteritis
(n=1). All eight patients presented with acute infarction lesions in ≥2
vascular territories. Most patients presented with numerous small and medium infarction
lesions located in the cortical and subcortical areas. Multiple stroke mechanisms were
involved in these cases, including hypercoagulability (n=4), cardiac
embolism (n=1) and vasculitis (n=3). Embolic signals
could be detected on transcranial Doppler in all three stroke mechanisms. In conclusion,
our study revealed the characteristics of autoimmune disease-related stroke. For patients
with multiple acute cerebral infarcts within non-single arterial territories, autoimmune
disease is an important etiology not to be neglected. Multiple stroke mechanisms were
involved in these cases.
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Affiliation(s)
- Li-Li Sun
- 1 Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Wen-Xiong Tang
- 1 Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Min Tian
- 1 Department of Neurology, China-Japan Friendship Hospital, Beijing, China
| | - Lu Zhang
- 2 Department of Rheumatology, China-Japan Friendship Hospital, Beijing, China
| | - Zun-Jing Liu
- 1 Department of Neurology, China-Japan Friendship Hospital, Beijing, China
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Grecu N, Tiu C, Terecoasa E, Bajenaru O. Endocarditis and stroke. MAEDICA 2014; 9:375-381. [PMID: 25705308 PMCID: PMC4316883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 12/05/2014] [Indexed: 06/04/2023]
Abstract
Endocarditis is an important, although less common, cause of cerebral embolism. All forms of endocarditis share an initial common pathophysiologic pathway, best illustrated by the non-bacterial thrombotic form, but also a final potential for embolization. Stroke associated with endocarditis has signifficant mortality and morbidity rates, especially due to the frequent concomitant multiple sites of brain embolization. In this article we aim to briefly review endocarditis with a focus on stroke as a complication, while also presenting case correlates from our department.
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Affiliation(s)
- Nicolae Grecu
- Department of Neurology, Emergency University Hospital, Bucharest, Romania
| | - Cristina Tiu
- Department of Neurology, Emergency University Hospital, Bucharest, Romania ; "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Elena Terecoasa
- Department of Neurology, Emergency University Hospital, Bucharest, Romania ; "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Ovidiu Bajenaru
- Department of Neurology, Emergency University Hospital, Bucharest, Romania ; "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
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