Nonbacterial Thrombotic (Marantic) Endocarditis in a Patient with Colorectal Cancer

Abstract

Background: Marantic endocarditis, presently termed nonbacterial thrombotic endocarditis (NBTE), is an infrequent post-mortem diagnosis in the adult population but a not so rare event in the course of neoplastic conditions. Case Report: We describe the case of a 74-year-old woman with advanced sigmoid adenocarcinoma, who developed aseptic vegetations in the right atrium of the heart. Systemic anticoagulation therapy was started, and upon clinical improvement systemic chemotherapy was added, resulting in partial response to antineoplastic therapy along with improvement of her cardiopulmonary status. A new cardiac assessment upon tumor recurrence was unable to distinguish the previously described lesions but disclosed a small mitral valve vegetation, in the absence of any signs or symptoms. The patient was again treated with chemotherapy and remains asymptomatic with stable disease. Conclusions: Although a hypercoagulable state may be etiologically related to malignant conditions, a strong clinical suspicion of NBTE is required. In these cases, it is often difficult to establish a definite diagnosis; however, immediate anticoagulation treatment is mandatory for the prevention of de novo or further thromboembolic events.

Trousseau Syndrome with Nonbacterial Thrombotic Endocarditis in a Patient with Uterine Cancer

“…NBTE is another mechanism underlying arterial thromboembolism encountered in patients with neoplastic diseases (3). NBTE is associated with many types of primary carcinomas, with lung, pancreatic and ovarian adenocarcinomas being the most frequently observed (6). An echocardiographic study of 200 living patients with various cancers found evidence of NBTE in approximately 19% of the patients, and evidence of NBTE was 10-fold higher in these patients than in a control group (7).…”

“…However, she exhibited no neurological deficits. The pathogenesis of NBTE in patients with malignancy remains partially elusive, although it is intimately related to cancer-associated thrombophilia, originally described as Trousseau syndrome (2,6). In the presence of excessive clotting factor activity, endothelial damage caused by circulating cytokines, such as tumor necrosis factor and interleukin-1, can trigger platelet deposition in areas of high blood flow (2,5,6).…”

“…The pathogenesis of NBTE in patients with malignancy remains partially elusive, although it is intimately related to cancer-associated thrombophilia, originally described as Trousseau syndrome (2,6). In the presence of excessive clotting factor activity, endothelial damage caused by circulating cytokines, such as tumor necrosis factor and interleukin-1, can trigger platelet deposition in areas of high blood flow (2,5,6). However, the pathogenesis of Trousseau syndrome may be more complicated, in that it may involve tissue factor and tumor-associated cysteine proteinase activity, tumor hypoxia, carcinoma mucin activity associated with platelet aggregation dependent on P-and L-selectins and oncogene activation related to hypercoagulability (9).…”

Marantic endocarditis – A not so benign entity

“…6 Left sided and bilateral vegetations are more consistent with marantic endocarditis than with the other major cause of vegetations, infective endocarditis. 8 Unlike marantic endocarditis, infective endocarditis is an infection of the endocardium which is frequently caused by bacteria such as Staphylococcus aureus and Streptococcus viridans, and occasionally fungi. The organisms induce platelet aggregation and activate the clotting cascade, leading to the deposition of fibrin and bacteria.…”

“…For example, a history of cardiac murmurs, which are characteristic of infective endocarditis, is often absent in marantic endocarditis. 8 Haematological and coagulation studies may have been normal but unexpected results should raise the suspicion of marantic endocarditis, especially when infective causes have been ruled out by negative blood cultures, or by a poor response to antibiotic therapy. 8 McKay and Wahler developed a triad to assist in diagnosing marantic endocarditis which consists of a history of a disease known to be associated with marantic endocarditis, a documented heart murmur, and a history of multiple systemic emboli.…”