Non-infectious thrombotic endocarditis associated with chronic rheumatic heart disease and disseminated tuberculosis

Rheumatic heart disease is still common in developing countries and requires prompt intervention to prevent chronic complications. Vegetations in rheumatic heart disease might be due to acute episodes of rheumatic fever itself or due to either infective endocarditis (IE) or Non-infectious thrombotic endocarditis (NITE). Each form of vegetations has specific pathological characteristics on gross and microscopic examination. However, clinically IE and NITE may have overlapping signs and symptoms. A chance of misdiagnosis of NITE as culture-negative infective endocarditis is higher if the former present with infective symptoms like fever. NITE of valves can be due to underlying associated malignant neoplasm, particularly mucinous adenocarcinoma, pneumonia, cirrhosis, autoimmune disorders, and hypercoagulable state. The coexistence of tuberculosis, non-infectious thrombotic endocarditis and rheumatic valvular heart disease was rarely documented in medical literature. We describe a case of chronic rheumatic heart disease with vegetations in the posterior mitral valve leaflet, treated as culture-negative infective endocarditis, which, at autopsy, reveals the presence of Nonbacterial thrombotic endocarditis vegetation over calcified, fibrosed mitral valve leaflets and associated disseminated tuberculosis along with classic pathological sequela findings of chronic rheumatic mitral valvular heart disease in lungs and liver.

Caracterización clínico-epidemiológica con enfoque quirúrgico de la endocarditis infecciosa en la región central de Cuba / Clinico-epidemiological characterization with a surgical approach of infective endocarditis in the central region of Cuba

RESUMEN Introducción: La endocarditis infecciosa no ha disminuido su incidencia y mortalidad en los últimos 30 años. Objetivo: Caracterizar los pacientes operados por diagnóstico de endocarditis infecciosa activa. Método: Se realizó un estudio descriptivo retrospectivo que incluyó a 109 pacientes con diagnóstico de esta enfermedad y fueron intervenidos quirúrgicamente en el Cardiocentro Ernesto Che Guevara (Cuba) desde julio de 2010 hasta junio de 2018. La información se obtuvo de las historias clínicas y el informe operatorio. Resultados: La endocarditis infecciosa sobre válvula protésica fue diagnosticada en 15 pacientes (13,8%), pero la más frecuente fue la relacionada con la colonización de dispositivos intracardíacos (51,4%), razón por la que el procedimiento quirúrgico más utilizado fue el cambio de sistema de estimulación. La principal indicación quirúrgica fue la infección incontrolada en 63 casos (57,8%), seguida por la insuficiencia cardíaca (38 pacientes; 34,9%) y en 67 casos (61,5%) los hemocultivos resultaron negativos. La sustitución de la válvula nativa por una prótesis mecánica se realizó en 28 pacientes (25,7%), de los cuáles 15 (13,8%) fueron en posición mitral. El recambio de una prótesis mecánica por otra de igual características se llevó a cabo en 14 (12,8%) casos, 8 (7,3%) de ellos mitrales. La mortalidad global fue de 17,4%, más evidente en aquellos con endocarditis sobre válvula protésica izquierda (7/15). Conclusiones: Predominaron el sexo masculino y la edad mayor de 60 años, así como la presencia de vegetaciones sobre dispositivos intracardíacos y los hemocultivos negativos. La endocarditis sobre válvula protésica se asoció significativamente con la mortalidad.

ABSTRACT Introduction: Infective endocarditis has not decreased its incidence and mortality in the last 30 years. Objective: To characterize patients operated on due to diagnosis of active infective endocarditis. Method: A retrospective, descriptive study was carried out, which included 109 patients with a diagnosis of this disease, who underwent surgery at Cardiocentro Ernesto Che Guevara (Cuba), from July 2010 to June 2018. The information was obtained from the medical records and the surgical report. Results: Prosthetic valve infective endocarditis was diagnosed in 15 patients (13.8%), but the most frequent was the one related to intracardiac device colonization (51.4%), reason why the most used surgical procedure was the change of the electrical stimulation system. The main surgical indication was the uncontrolled infection in 63 cases (57.8%), followed by heart failure (38 patients; 34.9%) and in 67 cases (61.5%), the blood cultures were negative. The native valve replacement for a mechanical prosthetic valve was performed in 28 patients (25.7%), of which 15 (13.8%) were in mitral position. The replacement of a mechanical prosthetic valve for another with the same characteristics was carried out in 14 (12.8%) cases, 8 (7.3%) of them were mitral. Overall mortality was of 17.4%, more evident in those with left-side prosthetic valve endocarditis (7/15). Conclusions: Male gender and age over 60 years old predominated, as well as the presence of vegetations on intracardiac devices, and negative blood cultures. The prosthetic valve endocarditis was significantly associated with mortality.

Endocarditis infecciosa en válvulas protésicas / Prosthetic valve endocarditis

RESUMEN Introducción: La endocarditis infecciosa sobre prótesis valvulares cardíacas es una de las formas más graves de esta enfermedad, de difícil diagnóstico y asociada con elevada mortalidad. Objetivo: Describir las características de la endocarditis infecciosa en válvulas cardíacas protésicas. Método: Se realizó un estudio observacional, descriptivo y transversal desde 2006 hasta 2019 en el Hospital Hermanos Ameijeiras. La muestra fue de 40 pacientes. Se utilizaron estadígrafos descriptivos como la media aritmética y la desviación estándar para las variables cuantitativas continuas y el porcentaje para las cualitativas. Resultados: La edad media de los pacientes fue de 54,29±16,07 años, predominaron aquellos con edades entre 40-49 y 60-69 años (27,5%), así como del sexo masculino (67,5%), y el tipo de endocarditis más frecuente fue la tardía 65%. La sepsis oral (27,5%) y la cirugía previa (25%) fueron la puerta de entrada más frecuente. Prevalecieron los cultivos negativos (40%) y los agentes causales estafilococos coagulasa negativos (25%) y estafilococos áureos (10%). En las complicaciones predominaron las insuficiencias cardíacas (32%) y renal (22,5%), y un 20% de los casos tuvo dehiscencia de sutura. El 52,5% de los pacientes recibió tratamiento quirúrgico y la mortalidad fue del 30%. Conclusiones: Predominó la endocarditis tardía, con hemocultivo negativo y de prótesis aórtica. La dehiscencia de prótesis fue el hallazgo ecocardiográfico más encontrado y la insuficiencia cardíaca, la complicación más frecuente. El tratamiento quirúrgico fue el más utilizado y la mortalidad, ajustada para esta enfermedad, fue baja.

ABSTRACT Introduction: Infective endocarditis in prosthetic heart valves is one of the most severe forms of this disease of difficult diagnosis and associated with high mortality. Objective: To describe the characteristics of prosthetic valve endocarditis. Method: An observational, descriptive and cross-sectional study was conducted from 2006 to 2019 at Hospital Hermanos Ameijeiras. The sample consisted of 40 patients. Descriptive statistics such as arithmetic mean and standard deviation were used for continuous quantitative variables, and percentage for qualitative ones. Results: The average age of the patients was 54.29+16.07 years old, predominating those between 40-49 and 60-69 years old, as well as males (67.5%); the most frequent type of endocarditis was the late one (65%). Oral sepsis (27.5%) and previous surgery (25%) %) were the most frequent entry points. Negative cultures (40%) and coagulase-negative staphylococcus causative agents (25%) and staphylococcus aureus (10%) prevailed. Heart failure (32%) and kidney failure (22.5%) were the most frequent complications, and 20% of cases had suture dehiscence. The 52.5% of patients received surgical treatment and the mortality was of the 30%. Conclusions: Late endocarditis predominated, with negative blood cultures and of aortic valve prosthesis. Prosthesis dehiscence was the most frequent echocardiographic finding and the heart failure, the most frequent complication. The surgical treatment was the most used, and the mortality, adjusted for this disease, was low.

Endocarditis secundaria a corynebacterium tras implante de válvula aórtica transcatéter: Informe de un caso / Endocarditis due to corynebacterium after transcatheter aortic valve implantation: A case report

RESUMEN Se presenta un caso de endocarditis valvular protésica secundaria a un organismo infrecuente (Corynebacterium sp.) tras la implantación de una protésis valvular aórtica percutánea. La menor sensibilidad del ecocardiograma transesofágico para detectar signos de endocarditis en éstos pacientes puede retrasar el diagnóstico. El uso de otras técnicas de imagen complementarias como la tomografía por emisión de positrones, puede ser de utilidad. El aumento de implantes de prótesis percutánea en los últimos años va asociado a un aumento de complicaciones como la endocarditis.

ABSTRACT We present a case of prosthetic valve endocarditis secondary to an infrequent organism (Corynebacterium sp.) after percutaneous aortic valve implantation. The lower sensitivity of transesophageal echocardiogram to detect signs of endocarditis in these patients may delay diagnosis. Implementing other ancillary imaging techniques such as positron emission tomography may be helpful. The increase in percutaneous prosthetic implants in recent years is associated with an upsurge in complications such as endocarditis

Endocarditis Marántica asociada a linfoma de Hodgkin / Marantic Endocarditis associated with Hodgkin's Lymphoma

La endocarditis trombótica no bacteriana (ETNB) se define como la presencia de trombos estériles sobre las válvulas cardiacas, corresponden a agregados de plaquetas y fibrina no infectados asociados a estados de hipercoagulabilidad como las neoplasias malignas, en donde se denomina también endocarditis marántica. Se presenta el caso de un paciente con historia de síndrome febril prolongado al que se le inició tratamiento antibiótico por una endocarditis infecciosa (EI) por presentar una imagen compatible con vegetación en el ecocardiograma transtorácico. Sin embargo, el paciente persistió febril y sin mejoría clínica, hasta que la biopsia de un ganglio cervical diagnosticó un linfoma de Hodgkin mejorando posteriormente con el tratamiento hemato específico(AU)

Non-bacterial thrombotic endocarditis (NBTE) is defined as the presence of sterile thrombi on the heart valves, correspond to non-infected platelet and fibrin aggregates associated with hypercoagulable states such as malignant neoplasms, which is also called Marantic Endocarditis. We present the case of a patient with a history of prolonged febrile syndrome who underwent antibiotic treatment for an Infective Endocarditis (EI) due to a compatible image with vegetation in the transthoracic echocardiogram. However, the patient persisted feverish and without clinical improvement, until the biopsy of a cervical ganglion diagnosed a Hodgkin lymphoma, improving later with the specific hemato treatment(AU)

Endocarditis por Pseudomonas spp: Descripción de un caso poco frecuente / Endocarditis caused by Pseudomonas spp: description of a rare case

RESUMEN Las infecciones por los dispositivos cardiovasculares son cada vez más frecuentes. Se presenta el caso de un hombre de 62 años edad con fiebre y toma del estado general, que había sido intervenido hacía siete años para la implantación de un marcapasos. En los complementarios se observaron leucocitosis y hemoglobina por debajo de 10 g/L; y en el ecocardiograma, un electrodo de marcapaso en cavidades derechas con múltiples masas ecodensas que indicaban endocarditis infecciosa. Se realizó extracción quirúrgica del dispositivo y cultivo de muestras de las vegetaciones, con aislamiento de Pseudomonas spp. Se administró terapia antimicrobiana sobre la base del antibiograma y el paciente evolucionó satisfactoriamente. Se debe pensar en esta enfermedad ante todo paciente con marcapasos que presente fiebre y sintomatología general, una vez que se han descartado otros posibles focos de infección; además, se debe actuar rápido para lograr un tratamiento adecuado.

ABSTRACT Infections due to cardiovascular devices are becoming more frequent. Here is presented the case of a 62-year-old male patient with fever and poor general condition, who had been intervened seven years ago for the implantation of a pacemaker. In the blood tests, leukocytosis and hemoglobin below 10 g/L were observed. The echocardiogram showed a pacemaker electrode in the right cavities with multiple echo-dense masses indicating infectious endocarditis. A surgical extraction of the device was performed as well as culture of vegetation samples with the isolation of Pseudomonas spp. An antimicrobial therapy was provided on the basis of the antibiogram, and the patient progressed satisfactorily. This clinical entity should be considered in any patient with a pacemaker who presents fever and general symptoms, once other possible sources of infection are ruled out; in addition to acting quickly in order to achieve an adequate treatment.

Ceguera cortical como manifestación inicial de endocarditis trombótica no bacteriana / Cortical blindness as initial manifestation of nonbacterial thrombotic endocarditis

La endocarditis trombótica no bacteriana, antiguamente conocida como endocarditis marántica, es una entidad infrecuente en la que se desarrollan vegetaciones estériles, compuestas por fibrina en las válvulas del corazón. Suele diagnosticarse en el momento de la autopsia o en enfermedades oncológicas avanzadas. Las neoplasias malignas más frecuentemente asociadas con esta entidad son las de pulmón, páncreas, estómago y adenocarcinomas de origen primario desconocido. Es necesario descartar la endocarditis infecciosa y establecer la presencia de vegetaciones valvulares mediante ecocardiografía. Presentamos el caso de una paciente con diagnóstico reciente de adenocarcinoma de estómago en estadio avanzado que presentó ceguera cortical e imágenes compatibles con isquemia cerebral. El ecocardiograma transesofágico mostró dos vegetaciones en válvula mitral. Los hemocultivos fueron negativos. Se enfatiza la importancia de sospechar endocarditis trombótica no bacteriana en enfermos con cáncer y embolismo sistémico.

Nonbacterial thrombotic endocarditis, formerly known as marantic endocarditis, it is an infrequent entity in which sterile, fibrin vegetations develop on heart valve leaflets. It is often diagnosed at the time of autopsy or in late-stage malignancies. The most common malignancies associated with nonbacterial thrombotic endocarditis are lung, pancreatic, gastric cancer and adenocarcinomas of an unknown primary site. Diagnosis requires ruling out infective endocarditis and establishing the presence of valvular vegetations using echocardiography. We report the case of a patient with a recent diagnosis of advanced gastric adenocarcinoma who presented with cortical blindness. The computed tomography was compatible with cerebral ischemia. The transoesophageal echocardiogram showed two vegetations in mitral valve. Blood cultures were negative. We emphasize the importance of suspecting nonbacterial thrombotic endocarditis in patients with cancer and systemic embolism.

Endocarditis marántica con embolia sistémica como manifestación de adenocarcinoma papilar de pulmón / Nonbacterial thrombotic endocarditis with systemic embolism as a manifestation of papillary lung adenocarcinoma

Resumen: Se presenta el caso de un hombre de 61 años, portador de un cáncer pulmonar en quien lesiones de aspecto embólico llevan al diagnóstico de Endocarditis marántica (no infecciosa). Se describen las características clínicas del paciente, los métodos diagnósticos incluyendo imágenes ecocardiográficas y la confirmación necrópsica.

Abstracts: A 61-year-old male with skin lesions suggesting embolic phenomena, was thoroughly investigated and a final diagnosis of marantic (non-infectious) endocarditis was established. Clinical characteristics and diagnostic investigation through laboratory test and images sustained the diagnosis. The use of transesophageal echocardiography is emphasized. This was finally confirmed by findings at necropsy.

Endocarditis marántica como presentación de cáncer de páncreas: caso clínico / Non-bacterial thrombotic endocarditis: report of one case

Marantic or nonbacterial thrombotic endocarditis is characterized for the presence of vegetations formed by a meshwork of fibrin and other cellular material similar a blood clot, without the presence of microorganisms. It is often related with tumors and chronic inflammatory states. We report a 49 years old female with a history of weight loss and asthenia, presenting with multiple cerebrovascular attacks and fever. Blood cultures were negative and the fever did not subside with antibiotic treatment. Trans esophageal echocardiogram showed a mitral valve vegetation and thickening of the free edge of both leaflets. In search of the etiology of such a case, a primary pancreatic cancer with distant metastases was found. We cannot rule out the differential diagnosis with bacterial endocarditis with negative blood cultures, although the clinical context supports a non-infectious etiology.

Non-Bacterial Thrombotic Endocarditis in a Patient with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is frequently associated with various extra-joint complications. Although rare, thromboembolic complications are associated with high morbidity and mortality. We experienced a very rare case of nonbacterial thrombotic endocarditis (NBTE) and subsequent embolic stroke in a patient with RA. A 72-year-old male with a 15-year history of RA suddenly developed neurologic symptoms of vomiting and dizziness. Brain magnetic resonance imaging revealed recently developed multiple cerebellar and cerebral lacunar infarctions. Echocardiography showed a pulsating mitral valve vegetation involving the posterior cusp of the mitral valve leaflet, which was confirmed as NBTE. Immediate anti-coagulation therapy was started. The NBTE lesion disappeared in follow-up echocardiography after 4 weeks of anti-coagulation treatment.

Enfermedad de Still del adulto asociada a endocarditis marántica: reporte clínico y revisión de literatura / Marantic endocarditis associate to adult Still's disease

Varón de 52 años, 9 meses de enfermedad, caracterizado por artralgias, fiebre alta, exantema evanescente, diaforesis, faringitis, astenia y baja de peso. Al examen: linfadenomegalia, taquicardia, soplo sistólico III/VI mitral y aórtico, Catalogado como fiebre de origen desconocido, Ecografía abdominal: hepato-esplenomegalia leve; ecocardiografía transesofágica: masa calcificada de 4,5 x 8 mm en válvula aortica y leve efusión pericárdica; tomografía abdominal: hepatoesplenomegalia leve, ganglios paraaórticos abdominales y una imagen captadora de contraste en hilio renal derecho de 15 x 25 mm, de bordes definidos. Leucocitosis neutrofílica, anemia moderada, ferritina > 2 000 ng/ ml., FR, ANA Y ANCA negativos. Ganglio cervical: reacción inflamatoria inespecífica; histopatología del tumor renal: carcinoma renal de células claras. A pesar de exéresis del tumor renal, la fiebre persistía; por exclusión, se diagnosticó enfermedad de Still del adulto (ESA) asociado a endocarditis trombótica no bacteriana (ETNB); recibió prednisona 1 mg/kg, con respuesta favorable. CONCLUSION. La ESA es un trastorno inflamatorio inmune caracterizado por la triada de fiebre, exantema evanescente y artralgias, asociado a otros signos y síntomas y pruebas de laboratorio inespecíficas, pero muy sugestivas. El diagnóstico es por exclusión. El tumor renal sed a la causa de ETNB y desencadenante de la ESA.

This is a 52-year-old male, with a 9-month of illness, characterized by arthralgias, high fever, evanescent rash, pharyngitis, weight loss. Examination, lymphadenopathy; tachycardia, III/VI systolic murmur in mitral and aortic areas. It was considered as fever of unknown origin. Abdominal ultrasound: mild hepato-splenomegaly; transesophageal echocardiography: calcified mass of 4,5 x 8 mm in the aortic valve and mild pericardial effusion; abdominal tomography: mild hepato-splenomegaly, abdominal para-aortic lymph nodes and an image with contrast uptake at the level of the right renal hilum of 15 x 25 mm, with defined borders. Moderate leukocytosis with neutrophilia, moderate anemia, ferritin > 2000 ng/mL, negative for RF, ANA and ANCA. Cervical lymph node: unspecific inflammatory reaction; histopathology from the renal tumor: clear-cell renal carcinoma. Despite removal of the renal tumor, the fever persisted; by exclusion, was diagnosed as adult Still's disease (ASD) associated with non-bacterial thrombotic endocarditis (NBTE); treatment was initiated with prednisone at 1 mg/kg, obtaining positive result. Conclusion. Adult Still's disease (ASD) is an immune disorder characterized by the trio fever, evanescent rash and arthralgia or arthritis, accompanied others signs and symptom and laboratory essay. The diagnosis is made by exclusion. The renal tumor would have been the cause of the NBTE and unchain of the ASD.

Non-Infective Endocarditis in a Patient with Rheumatoid Arthritis / 대한내과학회지

Pericarditis and atherosclerotic events are generally regarded as relatively common cardiac manifestations of rheumatoid arthritis (RA). However, RA-associated endocarditis is rarely reported, and can be confused (by clinicians) with an infective vegetation. Herein, we report a case of sterile endocarditis involving the mitral valve in a 36 year-old patient with longstanding RA; the problem was accidentally detected during performance of a valve operation.

Multiple Hypercoagulability Disorders at Presentation of Non-Small-Cell Lung Cancer / 결핵및호흡기질환

Hypercoagulability disorders are commonly encountered in clinical situations in patients with a variety of cancers. However, several hypercoagulability disorders presenting as first symptoms or signs in cancer patients have rarely been reported. We herein described a case of a woman with adenocarcinoma of the lung presenting with deep vein thrombosis, nonbacterial thrombotic endocarditis, recurrent cerebral embolic infarction, and heart failure.