Nonbacterial Thrombotic Endocarditis of the Tricuspid Valve Associated with Pancreatic Adenocarcinoma: A Case Report

Case Report

Ann Hematol Oncol. 2016; 3(3): 1080.

Nonbacterial Thrombotic Endocarditis of the Tricuspid Valve Associated with Pancreatic Adenocarcinoma: A Case Report

Sochat MM¹*, Kailasam MT² and Dotan E³

¹Department of Internal Medicine, Temple University Hospital, USA

²Department of Internal Medicine, Fox Chase Cancer Center, USA

³Department of Medical Oncology, Fox Chase Cancer Center, USA

*Corresponding author: Matthew M Sochat, Department of Internal Medicine, Temple University Hospital, 3401 North Broad Street, Philadelphia, USA

Received: March 31, 2016; Accepted: May 25, 2016; Published: May 27, 2016


Nonbacterial thrombotic endocarditis, also known as marantic endocarditis, is a disorder characterized by the deposition of sterile vegetations on the heart valves. It occurs in the context of noninfectious chronic inflammatory conditions, particularly visceral malignancies. These vegetations are much more prone to detach and embolize as compared to infectious endocarditis, and patients typically present with the signs and symptoms of systemic arterial emboli, such as ischemic cerebral infarctions and acute coronary syndromes. The left heart valves are most commonly involved, although right heart valve involvement can rarely be seen. It is typically managed by treating the underlying cause of inflammation and administering anticoagulation. Here we present the case and associated literature review of a patient with metastatic pancreatic tail adenocarcinoma, prior deep venous thromboses and pulmonary emboli on rivaroxaban therapy, presenting with ischemic strokes secondary to nonbacterial thrombotic endocarditis, with tricuspid valve involvement.

Keywords: Anticoagulation; Endocarditis; Nonbacterial; Pancreatic neoplasms; Thrombosis; Tricuspid valve


CT: Computed Tomography; DCIS: Ductal Carcinoma In Situ; DIC: Disseminated Intravascular Coagulation; DVT: Deep Venous Thrombosis; DWI: Diffusion-Weighted Imaging; MRI: Magnetic Resonance Imaging; NBTE: Nonbacterial Thrombotic Endocarditis; NOAC: Novel Oral Anticoagulant; PE: Pulmonary Embolism; SLE: Systemic Lupus Erythematosus; TEE: Transesophageal Echocardiography; TTE: Transthoracic Echocardiography; VTE: Venous Thromboembolism

Case Presentation

A 74-year-old female presented to our urgent care center with one day of generalized weakness, nausea, vomiting, gait imbalance, and numerous falls. She reported no similar symptoms prior to this and denied any focal symptoms including weakness or sensory loss. She denied both systemic symptoms of fever, chills and sweats as well as focal respiratory, urinary or gastrointestinal symptoms; her appetite was only modestly decreased. One month prior to this presentation, she was diagnosed with adenocarcinoma of the pancreatic tail with metastatic disease to the lungs and liver. This was confirmed with a biopsy of a metastatic liver lesion. Simultaneously she was found to have bilateral deep venous thromboses (DVTs) and pulmonary emboli (PEs). She had been initiated on rivaroxaban therapy at that time. One week prior, she had presented to our institution for consideration of systemic chemotherapy.

During her initial evaluation, her vital signs were stable, and she was afebrile. Orthostatic vital signs were negative. Initial neurological exam was notable for gait ataxia, but was otherwise non-focal. Cardiopulmonary examination revealed clear lungs and no evidence of abnormal heart sounds. She had stable right upper extremity lymphedema following a remote lumpectomy 28 years prior for ductal carcinoma in situ (DCIS), and no evidence of lower extremity edema. The abdomen was mildly tender throughout but otherwise benign, the remainder of her initial examination was normal.

An initial complete blood count revealed hemoglobin of 13.1 g/ dL, white blood cell count of 15,000 cells/mm3 and platelet count of 192,000/mm3. Her comprehensive metabolic panel showed alkaline phosphatase of 218 units/L, but was otherwise unremarkable. Noncontrast computed tomography (CT) scan of the head was performed and negative for any pathology. She was admitted for observation and rehydration overnight.

Serial neurological exams over the course of the following day revealed the evolution of left hemineglect and subsequently left face, arm, and leg weakness and sensory deficits that were not seen on admission. Magnetic resonance imaging (MRI) of the brain was performed, which revealed scattered acute bilateral anterior and posterior circulation ischemic infarctions on diffusion weighted imaging (DWI) sequences (Figure 1). A subsequent bilateral carotid artery duplex study was unremarkable. Transthoracic echocardiography (TTE) revealed a medium-sized (11 mm by 8 mm), verrucoid, solid, fixed vegetation on the tip of the posterior tricuspid valve leaflet (Figures 2, 3). No left-sided vegetations were detected and all other cardiac parameters, including tricuspid valve function, were normal, although a bubble study was not performed, and it is not known if an intra-cardiac shunt was present.