Table 2.

Comparison of Previous Case Reports of Gallbladder-Associated Nonbacterial Thrombotic Endocarditis and This Clinical Vignette

	Case 112	Case 211	Case 313	Case 4 (this clinical vignette)
Patient age and gender	41-year-old woman	68-year-old man	62-year-old woman	63-year-old woman
Presenting clinical symptoms	Acute left hemiparesis	Acute chest pain with development of fevers, bilateral pitting edema, visual field loss, confusion, ataxia	Acute left hemiparesis	Acute left hemiparesis
Initial exam findings	Left facial and upper extremity motor weakness	One nailbed splinter hemorrhage, leg pitting edema, bilateral inferior hemianopia, diastolic murmur	Left upper and lower limb motor weakness	Left nasolabial flattening and upper extremity motor weakness
Subsequent clinical findings	Seizures on hospital day 2	Deterioration with obtundation, arterial emboli to the right lower limb, and cardiovascular collapse during hospitalization	Left hemispatial neglect and sensory change found on transfer to new hospital 1 week after presentation	Lethargy, confusion, left-sided neglect, dysarthria 2 weeks after initial presentation during hospitalization for DRESS
Notable lab findings	Not reported	Elevated CRP and ESR, normal lumbar puncture labs	Elevated CEA, elevated d-dimer; normal PT, PTT, fibrinogen, ATIII	Initial: normal PT and INR After acute new onset stroke*: PT 24.3, INR 2.3, PTT 47.4, normal fibrinogen; elevated CA 19-9
Brain imaging findings	CT (initial): negative CTA (1 day after presentation): occlusion of the cortical branches of the right MCA CT (with clinical deterioration): new ischemic lesions in both hemispheres	MRI (at initial presentation): restricted diffusion in white matter and cortical sulci with edema in right temporal region	MRI (initial): negative MRI (1 week following initial presentation): multiple cerebral and cerebellar infarctions MRA (1 week after presentation): right ICA occlusion	MRI (initial): multiple acute infarcts in the right frontal lobe, parietal lobe, and basal ganglia, and left frontal and parietal lobe CTA (initial): right ICA, ACA, and MCA filling defects MRI (after new acute symptoms): acute infarcts of right frontal lobe, right parietal lobe, insular cortex, basal ganglia, corona radiata, centrum semiovale
Vegetation location	Aortic and mitral valves	Aortic valve	Mitral valve	Aortic and mitral valves
Management	IV heparin and low molecular dextran	Broad-spectrum antibiotics Urgent aortic valve replacement	IV heparin Surgical resection of gallbladder	Initially started on apixaban and broad-spectrum antibiotics After acute recurrent stroke: IV heparin then LMWH Outpatient chemotherapy
Prognosis	Hospitalization complicated by seizures due to recurrent ischemic strokes leading to cerebral edema and brain death; died on hospital day 6	Hospitalization complicated by hemodynamic instability and new onset ascites leading to urgent valve replacement and abdominal laparoscopic exploration; transitioned to comfort care and died shortly after	Disappearance of vegetation on transesophageal echocardiogram 2 weeks after initiation of heparin; no known recurrence of stroke	No known recurrence of stroke
Valve histopathology findings	Loosely adherent aortic and mitral valve vegetations with fibrin; valvular leaflet without destruction or bacteria	Fibrinous aggregations with mixed inflammatory cell infiltrate and scanty neutrophils and degenerate histiocytes without identification or later growth of microorganisms	N/A	N/A
Malignancy/histopathology findings	Mass filling gallbladder cavity Histopathology: adenocarcinoma	Large intra-hepatic solid lesion, a thickened gallbladder, extensive omental seeding Histopathology: disseminated adenocarcinoma	24 mm mass on gallbladder Histopathology: poorly differentiated tumor cells and the production of mucin	Abnormally focal circumferential thickness of gallbladder fundus, enlarged porta hepatis lymph node Histopathology: biliary adenocarcinoma on nodal biopsy
Associated malignancy	Gallbladder adenocarcinoma (no reported mucin)	Probable primary gallbladder adenocarcinoma with omental seeding (no reported mucin)	Mucin-producing gallbladder carcinoma	Probable primary gallbladder malignancy without mucin production with involvement of the porta hepatis node

ACA anterior cerebral artery, ATIII antithrombin III, CEA carcinoembryonic antigen, CRP C-reactive protein, CT computerized tomography, CTA computerized tomography angiography, DRESS drug reaction with eosinophilia and systemic symptoms, ESR erythrocyte sedimentation rate, ICA internal carotid artery, INR international normalized ratio, LMWH low molecular weight heparin, MCA middle cerebral artery, MRI magnetic resonance imaging, MRA magnetic resonance angiography, PT prothrombin time, PTT partial thromboplastin time

*Patient on a direct oral anticoagulant at time of labs