Antemortem diagnosis of nonbacterial thrombotic endocarditis in a patient with previously resected pancreatic adenocarcinoma: a case report

Abstract

Background Nonbacterial thrombotic endocarditis (NBTE) is a rare manifestation of a number of systemic diseases, which include advanced malignancy and hypercoagulable states. Case summary We present a 67-year-old woman who had presented with chest pain and heart failure. Eight years ago, she had a successful Whipple resection for pancreatic adenocarcinoma. Echocardiography revealed mitral valve vegetations with negative blood cultures. She had multiple infarcts in the kidney, spleen, and brain. She was found to have a mass in the left 8th rib, consistent with metastatic pancreatic adenocarcinoma on biopsy. Ultimately, a diagnosis of NBTE was made after excluding other causes for her presentation. Because of her general poor condition, she expressed the wish for palliative care and later died 28 days after presentation. Discussion This case illustrates the possibility of NBTE in patients successfully treated for pancreatic adenocarcinoma and highlights the consideration of this relatively rare differential in patients with a previously treated malignancy presenting with heart failure.

The Reply

“…2 Two-thirds of patients (n = 28, 66.7%) presented this way in our study, with the cerebral (n = 25) and coronary circulations (n = 3) being the major targets. 1 Heart failure symptoms and signs at presentation, which were also reported in prior case reports, 3,4 were observed in 9 of 42 patients (21.4%) in our study. 1 In terms of other presentations, these included vague symptoms or nonspecific signs as described in previous case reports, 5 such as altered mental status, dizziness, and generalized weakness.…”

Esophageal Adenocarcinoma Causing Nonbacterial Thrombotic Endocarditis

“…The vegetation is made from thrombi intermixed with strands of fibrin, platelets, mononuclear cells, and immune complexes. The vegetation is without bacteria or inflammation [ 4 ]. This mix of substances causes the vegetation to be friable and easily embolize, like the patient in our case.…”

“…In this case, there was an absence of fever and heart murmur, four sets of negative blood cultures, and a lack of improvement after antibiotic therapy. The only way to definitively diagnose NBTE is histology through specimen acquisition [ 4 ]. This is rarely done while the patient is alive.…”