Behind Recurrent Thromboembolic Events

Abstract

We describe the case of a 68-year-old man, who presented with an ischemic stroke due to cardiac embolization related to mitral valve endocarditis. Blood cultures were always negative and post-operative valve histology did not show microorganisms. The patient also presented further recurrent peripheral embolic events. These clinical aspects were the first sign of a pancreas adenocarcinoma, which was only diagnosed in the clinical autopsy. In conclusion, these clinical findings of recurrent thromboembolic events with no microorganisms isolated suggests the diagnostic of a marantic endocarditis. LEARNING POINTS• Marantic endocarditis is characterized by the deposition of fibrin and thrombi on heart valves in the absence of microorganisms.• Is associated with higher incidence of thromboembolic events and most commonly found in patients with neoplasia in post-mortem studies.• It is a diagnostic challenge to distinguish from infective endocarditis and a high clinical suspicion is crucial to confirm the diagnosis. KEYWORDS Marantic endocarditis; thromboembolism; pancreatic adenocarcinoma CASE REPORT A 68-year-old man was admitted to the emergency department of our hospital with 1-hour evolution of left hemiparesis and hypoesthesia, left facial paralysis and mild dysarthria. Cranial Computed Tomography (CT) showed aspects suggesting right hemispheric acute ischemic stroke. The initial laboratory blood tests revealed a platelet count of 74.000/mm 3 , which contraindicated the thrombolytic treatment. The other lab results were within normal ranges values. Chest X-ray and 12-lead electrocardiography findings were normal. The patient's medical history included hypertension, chronic gastritis and small hiatus hernia; he was a former smoker, with moderate alcoholic habits. To clarify the aetiology of stroke, a transthoracic echocardiography (TTE) was done and revealed a mobile and echodense lesion on the atrial surface of posterior mitral valve leaflet suggesting a vegetation. The transesophageal echocardiography (TEE) showed the vegetation with 20mm of major diameter, mild mitral regurgitation and no leaflet destruction (Fig. 1). As such, the diagnostic of infective endocarditis was admitted and empiric antibiotic therapy was initiated, with gentamicin and vancomycin. Serial blood cultures remained sterile, despite the extension of incubation time to 21 days. Serologic tests for atypical microorganisms were negative. The immunologic evaluation was unremarkable.