A 46-year-old male with advanced adenocarcinoma of the lung presented with venous thrombosis. Despite anticoagulants, he developed a stroke and bowel ischaemia. Echocardiography revealed mobile structures on the mitral valve and at the pulmonary artery origin (Fig. 1). Although treatment for endocarditis and pulmonary embolism was initiated, his condition deteriorated. However, blood cultures remained negative and fever was absent. Non-bacterial thrombotic endocarditis (NBTE) became more likely after establishing progressive malignancy with PET-CT. NBTE is found in 19% of patients with malignancy and thrombotic events, but often not recognised [1]. It is distinguished from infective endocarditis by location of the valvular mass, absence of infection, diffuse thickening of valve leaflets and usual absence of valvular dysfunction [2, 3]. Treatment involves oncological therapy and anticoagulants [4]. Surgery may be considered in progressive valvular disease or recurrent embolism [5]. NBTE should be part of the differential diagnosis in patients with malignancy and thromboembolic complications.
Fig. 1.
Transthoracic (a) and transoesophageal echocardiography (b) revealing a mobile structure attached to the ventricular side of the anterior mitral valve leaflet and multiple mobile masses at the origin of the pulmonary artery
References
- 1.Edoute Y, Haim N, Rinkevich D, et al. Cardiac valvular vegetations in cancer patients: a prospective echocardiographic study of 200 patients. Am J Med. 1997;102:252–258. doi: 10.1016/S0002-9343(96)00457-3. [DOI] [PubMed] [Google Scholar]
- 2.Reisner SA, Brenner B, Haim N, et al. Echocardiography in nonbacterial thrombotic endocarditis: from autopsy to clinical entity. J Am Soc Echocardiogr. 2000;13:876–881. doi: 10.1067/mje.2000.106070. [DOI] [PubMed] [Google Scholar]
- 3.Saric M, Armour AC, Arnaout MS, et al. Guidelines for the use of echocardiography in the evaluation of a cardiac source of embolism. J Am Soc Echocardiogr. 2016;29:1–42. doi: 10.1016/j.echo.2015.09.011. [DOI] [PubMed] [Google Scholar]
- 4.Whitlock RP, Sun JC, Fremes SE, et al. Antithrombotic and thrombolytic therapy for valvular disease: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e576S–e600S. doi: 10.1378/chest.11-2305. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.El-Shami K, Griffiths E, Streiff M. Nonbacterial thrombotic endocarditis in cancer patients: pathogenesis, diagnosis, and treatment. Oncologist. 2007;12:518–523. doi: 10.1634/theoncologist.12-5-518. [DOI] [PubMed] [Google Scholar]