Nonbacterial Thrombotic Endocarditis Due to Primary Gallbladder Malignancy with Recurrent Stroke Despite Anticoagulation: Case Report and Literature Review

Abstract

Nonbacterial thrombotic endocarditis (NBTE) associated with malignancy is rare; its infrequency and similarity to other diagnoses make it a significant diagnostic challenge. A 63-year-old woman on rivaroxaban for prior deep vein thrombosis presented with left upper extremity weakness and left facial droop with imaging demonstrating multiple strokes. Echocardiograms revealed mitral and aortic valve vegetations. The patient was switched to apixaban and started on vancomycin and ceftriaxone for presumed culture-negative endocarditis. Despite continuing apixaban, her hospital course was complicated by new acute embolic infarcts. Workup confirmed nonmucinous metastatic biliary adenocarcinoma. The patient was placed on a heparin drip then switched to low molecular weight heparin without further embolic events and was discharged to a rehabilitation facility in stable condition with plans for chemotherapy as an outpatient. These clinical, imaging, and histologic findings were consistent with a rare case of NBTE associated with primary non-mucinous gallbladder malignancy complicated by recurrent strokes in which direct oral anticoagulants did not provide adequate anticoagulation.

Lung Cancer as a Leading Cause among Paraneoplastic Non-Bacterial Thrombotic Endocarditis: A Meta-Analysis of Individual Patients’ Data

“…The flow chart of our included studies is shown in Supplementary Figure S1 . Around 25% (39) of included studies were from the USA, and only 1 study was reported from China [ 19 , 22 , 23 , 24 , 27 , 29 , 32 , 33 , 34 , 39 , 41 , 43 , 46 , 47 , 48 , 57 , 58 , 59 , 68 , 69 , 73 , 76 , 81 , 84 , 86 , 88 , 92 , 93 , 94 , 100 , 101 , 105 , 108 , 111 , 114 , 115 , 118 , 131 , 132 , 136 ]. A list of the included studies and the quality assessment are reported in Supplementary Table S2 .…”

Thrombosis of Chiari’s network in the setting of non-bacterial thrombotic endocarditis occurring under non-vitamin K antagonist oral anticoagulation: a case report

“… 9 NOACs have not been evaluated and seem inefficient as reported by some case reports in the literature. 12 , 13 , 14 , 15 …”

A rare case of metastatic pancreatic adenocarcinoma presenting as a pulmonary embolism from nonbacterial thrombotic endocarditis

“…In the era of direct oral anticoagulants, there is currently not enough data to support their use in cancer-related NBTE. Recently, a few cases were reported in which patients with cancer-associated NBTE on optimized doses of rivaroxaban had developed multiple discrete embolisms [12] , [13] , [14] .…”