Marantic endocarditis: incidental infarcts leading to diagnosis of pancreatic cancer

Abstract

Non-bacterial thrombotic endocarditis (NBTE) is a well-described phenomenon associated with malignancies due to hypercoaguable state. In the setting of pancreatic cancer, NBTE is more commonly diagnosed postmortem. We describe a case of a man who was diagnosed with pancreatic carcinoma after incidental finding of NBTE. Imaging incidentally revealed multiple strokes, bilateral renal and splenic infarcts, while subsequent workup for cardioembolic source demonstrated a 1.1×0.7 cm mitral valve vegetation. As multiple blood cultures were sterile and patient lacked clinical signs of infection, an underlying malignancy was suspected. CT abdomen demonstrated a dilated pancreatic duct, MRI showed a 2.8×2.2 cm pancreatic head mass. Endoscopic biopsy of the mass revealed pancreatic adenocarcinoma. Other than NBTE, there were no other clinical or laboratory findings to clearly suggest pancreatic cancer. Thus, incidental discovery of this mitral valve vegetation led to the diagnosis of pancreatic malignancy.

Atypical marantic endocarditis

“…Although, transoesophageal echocardiogram (TOE) is more sensitive than TTE, two-dimensional TTE is the first choice with TOE reserved for cases where TTE is unrevealing, with suitable patients 1. Our echocardiographic findings are consistent with the findings of previously published cases 8 18…”

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 .…”

“…In general, the prognosis of marantic endocarditis is good, as the vegetations are usually small and do not typically cause significant damage to the heart valves. Many patients with marantic endocarditis do not experience symptoms, and the condition may be discovered incidentally on an echocardiogram or in other imaging studies [ 118 , 158 ]. However, as we mentioned before, in some cases, the vegetations can cause emboli that can result in serious complications such as stroke, heart attack, or organ damage [ 31 , 69 , 74 ].…”

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

“…In this unique process, the valvular tissue involved is typically normal or with a minimal exhibition of abnormal elastic fibers or collagen [2] . NBTE has been associated with proinflammatory scenarios such as malignancy, where inflammation releases both interleukin-1 (IL-1) and tumor necrosis factor (TNF) which act toward damaging tissue, leading to thrombus deposition [6] . In contrast to bacterial IE, these patients are found to have an absence of bacteremia [2] .…”