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We present 3 cases of cardiac papillary fibroelastoma (PFE) revealed by acute ischemic stroke (table). Case 1 is a 38-year-old man who presented with sudden expressive language disorder and right hemiparesis. CT angiography showed a left middle cerebral artery (MCA) occlusion. Acute reperfusion therapy with endovascular thrombectomy (EVT) was achieved successfully. He was monitored in a stroke unit. The aspirated tissue was macroscopically congruent with a fibrin clot but the material was insufficient for pathologic analysis. A brain MRI performed a few days after admission showed a subacute ischemic stroke (figure, A). Blood tests, including hypercoagulability and autoimmunity assays, were normal or negative. Serial EKG and EKG Holter showed sinus rhythm. Transthoracic echocardiography (TTE) revealed an intracardiac mobile mass, with no history of fever or general malaise and negative blood cultures, suggestive of a primary cardiac tumor. Transesophageal echocardiography (TEE) (figure, B) confirmed the presence of an 11-mm pediculate mass bulging from the auricular surface of the mitral valve, with no valve or cardiac dysfunction. The suspicion of a primary cardiac tumor was supported. Case 2 is a 64-year-old man who presented with sudden left hemiparesis and dysarthria. CT angiography showed a right MCA occlusion. Endovascular acute reperfusion was attempted, but when the arteriography was performed, there had been a distal migration of the thrombus. He was monitored in a stroke unit. A brain MRI showed an established stroke (figure, A). Blood tests and EKG Holter were normal. TTE showed a pediculate mobile mass on the mitral valve. TEE (figure, B) confirmed its presence, 14 mm, in absence of valve dysfunction. There was no history of fever, raising the suspicion of a primary cardiac tumor. Case 3 is a 73-year-old man who presented with sudden expressive language disorder and right hemiparesis. There was no established stroke or arterial occlusion on CT scan/CT angiography. IV alteplase (recombinant tissue plasminogen activator [rtPA]) was administered in a stroke unit, with a good response. The brain MRI demonstrated a left temporoparietal stroke (figure, A). Blood tests were normal. Serial EKG and EKG Holter showed sinus rhythm. TTE revealed an auricular mass. TEE (figure, B) defined a 9-mm pediculate mass with frayed edges bulging from the left atrial appendage, suggestive of a primary cardiac tumor. There was no cardiac dysfunction.

Progressive multifocal leukoencephalopathy (PML) is an opportunistic infection of the central nervous system caused by JC virus. Only ten cases of PML have been reported so far in liver transplant recipients. We present a case of liver posttransplantation PML with characteristic clinical and brain MRI findings, but with an atypical late onset, developed 11 years after transplantation and after single-drug, long-term (8 years), and low-dose (750 mg twice a day) immunosuppression with mycophenolate mofetil (MMF). This is the latest onset of PML associated to liver transplant reported. The present case should help physicians to be aware of PML after transplantation, even in the long term and even under low doses of immunosuppressants, especially MMF.

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