Nonbacterial Thrombotic Endocarditis with Recurrent Embolic Events as Manifestation of Ovarian Neoplasm

Abstract

We describe the case of a 43-year-old woman with transient ischemic neurologic deficits and recurrent systemic and pulmonary emboli in whom infectious work-up and extensive thrombophilic evaluation were unremarkable. Transesophageal echocardiography (TEE) established the diagnosis of nonbacterial thrombotic endocarditis (NBTE). This is a rare condition often associated with hypercoagulable states or advanced malignancy such as adenocarcinomas, characterized by cardiac vegetations along valvular coaptation lines without destruction of leaflets. In our patient, we diagnosed an ovarian clear cell adenocarcinoma, a malignant disorder that has been rarely reported in association with NBTE. This case illustrates that NBTE can present as an atypical manifestation of malignancy and must be distinguished from infective endocarditis, which implies a different therapeutic strategy. When confronted with findings of NBTE without a clear etiology, an occult neoplasm must be excluded. Anticoagulant therapy is the mainstay of treatment. However, cardiac vegetations may require surgical intervention in rare instances.

Nonbacterial Thrombotic Endocarditis Leading to Acute Heart Failure due to Aortic Stenosis in a Patient with Lung Cancer

“…Most of the symptoms of NBTE are related to embolic events, primarily cerebral embolism, often leading to cortical symptoms, such as unilateral paralysis, aphasia and agnosia (4,12). Other sites prone to emboli originating from NBTE include the coronary arteries, spleen and kidneys (13). However, it is extremely rare that NBTE causes cardiac valve lesions and acute heart failure, as in the present case.…”

Multiple embolic cerebral infarcts as the first manifestation of metastatic ovarian cancer

“…There are other mechanisms that link cancer to stroke and these have been documented in other case reports of ovarian cancer presenting as cerebral infarction 17 18. They include non-bacterial thrombotic endocarditis, where sterile vegetations grow on the aortic and/or mitral valve, and are thought to be composed of disrupted fibrin and platelets, and are susceptible to embolisation 17.…”

Ovarian cancer with initial symptom of pulmonary embolism: A case report

“…A study of cerebral infarction associated with ovarian cancer has identified the main cause as NBTE or hypercoagulability [9]. The hypercoagulable state in patients with ovarian cancer cannot be influenced by standard anticoagulation therapy with heparin or coumadin derivatives, but it has been reported to be stopped by curative resection of the tumor, avoiding an extremely poor outcome [10,11]. Treatment of the hypercoagulable state itself does not have a great influence on prognosis; successful treatment of the primary disease is said to most influence the prognosis.…”