A 37-year-old woman affected by uterine HPV-related adenocarcinoma complicated by paraneoplastic pulmonary thromboembolism, came to the emergency department for recurrent episodes of dysarthria and blurred vision with spontaneous resolution.
Home medications: Enoxaparin 5000 UI b.i.d, levofloxacin 500 mg/die, deltacortene 25 mg/die and omeprazole 20 mg/die.
Blood analysis: normocytic anemia (Hb 9 gr/dl) ,elevated D-dimer (22.5 mcg/ml) and elevated C-reactive protein (18.3 mg/dl). Procalcitonin and blood cultures resulted negative.
Brain CT scan: ischemic brain lesions of embolic nature in the right precentral gyrus and in the left post central gyrus.
EKG: sinus rhythm, T-wave inversion in inferior leads.
In the suspect of cardioembolic stroke a transthoracic (TTE) and subsequent transesophageal (TOE) echocardiography was performed:
TTE: isoechoic oval-shaped thickening of the aortic valve cusp tips, producing aortic regurgitation with double jet regurgitation.
TOE: evidence of multiple isoechoic masses involving all the aortic cusps, without perivalvular aortic extension, producing significant aortic regurgitation due to coaptation- gap (Figure 1).
The diagnosis of non-bacterial thrombotic endocarditis (NBTE) was made up.
Although the standard medical therapy (anticoagulation and chemotherapy) was promptly started, it wasn’t effective with progression of the disease leading to surgical indications of valve intervention.
The patient underwent aortic valve replacement with bioprosthesis avoiding mechanical prosthesis, despite the young age, in anticipation of major surgery for the uterine cancer. Surgical specimen turned negative for microorganism growth confirming the diagnosis of marantic endocarditis.
No further episodes of ischemic stroke appeared after the replacement of the valve and the patient had no neurological sequelae.
NBTE is a rare condition of non-infective endocarditis characterized by the formation of aggregates of platelets and fibrin that affects usually undamaged heart valves in the absence of bacteremia and mostly occurs in patients with a predisposing state like hypercoagulability. Surgical indications of valve intervention are not well encoded but in most cases they follow the raccomandations for infective endocarditis. Our experience highlights the need of a prompt intervention in order to reduce the damage of systemic embolization and preserve patient’s hemodynamics with a strict checking of disease progression.