Rare Association of Non-Bacterial Thrombotic Endocarditis, Myocardial Infarction, and Acute Limb Ischemia Secondary to Rheumatoid Arthritis: Comprehensive Case Series With Literature Review

Abstract

Most cases of non-bacterial thrombotic endocarditis (NBTE) tend to be related to malignancy or rheumatologic and autoimmune disorders like systemic lupus erythematosus. Rheumatoid arthritis (RA) itself has been associated with increased atherosclerosis, coronary artery plaque formation, and endothelial damage. However, it is rare to see NBTE in RA, simultaneously presenting with the acute coronary syndrome and acute limb ischemia due to distant embolization. Here we present a case of a 46-year-old female presenting with chest pain and right leg numbness, found to have ST-elevation myocardial infarction (STEMI) and occlusion of a peripheral artery due to embolization of vegetation present in the aortic valve. We also provide an extensive literature review of the relationship between NBTE and MI. One must be extra vigilant in managing these patients, especially if the size of vegetation is large as it has a tendency to embolize causing devastating complications.

Left ventricular free-wall rupture: An unusual presentation of non-bacterial thrombotic endocarditis

“…Although systemic embolization occurs in up to 50% of NBTE cases, this is usually asymptomatic and lifethreatening stroke and MI are rare complications. 5 Acute embolic complications of NBTE have been previously reported, 6,7 but to the best of our knowledge, this is the first reported case of NBTE complicated by LVFWR.…”

Polymorphic lymphoproliferative disorder arising in a rheumatoid arthritis patient, presenting as fibrin‐associated large B‐cell lymphoma‐like lesions in aortic and mitral valves

“…12 Although rare, NBTE associated with RA has been reported. 13 It is possible that the tumor cells would proliferate in the pre-existing NBTE. The resected valve showed mild myxoid changes, possibly linked to subclinical valve injury.…”

“…Nonbacterial thrombotic endocarditis (NBTE) is characterized by the presence of vegetations on heart valves, which consist of fibrin and platelet aggregates without inflammation or bacteria 12 . Although rare, NBTE associated with RA has been reported 13 . It is possible that the tumor cells would proliferate in the pre‐existing NBTE.…”

Diagnostic Work-Up in Patients with Nonbacterial Thrombotic Endocarditis

“…In the case of other autoimmune diseases, sterile thrombotic endocardial vegetations have been described also in patients with rheumatoid arthritis [38][39][40], inflammatory myositis [41], systemic sclerosis [42,43], Behçet's disease [44], Crohn's disease [45][46][47], and vasculitis, particularly with anti-neutrophil cytoplasmic antibodies (ANCA) [48][49][50][51] and giant-cell arteritis [52,53] (Table 1). Patients diagnosed with NBTE without a definite diagnosis of an autoimmune condition are more likely to test positive for rheumatoid factors [5].…”

“…In the case of other autoimmune diseases, sterile thrombotic endocardial vegetations have been described also in patients with rheumatoid arthritis [ 38 , 39 , 40 ], inflammatory myositis [ 41 ], systemic sclerosis [ 42 , 43 ], Behçet’s disease [ 44 ], Crohn’s disease [ 45 , 46 , 47 ], and vasculitis, particularly with anti-neutrophil cytoplasmic antibodies (ANCA) [ 48 , 49 , 50 , 51 ] and giant-cell arteritis [ 52 , 53 ] ( Table 1 ).…”