Rankin William R, Querin Lauren B, Free Megan, Martini Wayne A
Emergency Medicine, Mayo Clinic Alix School of Medicine, Scottsdale, USA.
Emergency Medicine, Mayo Clinic Arizona, Phoenix, USA.
Cureus. 2024 Oct 5;16(10):e70887. doi: 10.7759/cureus.70887. eCollection 2024 Oct.
Nonbacterial thrombotic endocarditis (NBTE) is a rare but serious complication, particularly in patients with malignancies like acute myeloid leukemia (AML), where a hypercoagulable state increases the risk of embolic events. This case report describes a rare and complex presentation of marantic endocarditis in a 78-year-old female with relapsed AML. The uniqueness of this case lies in the intersection of a hypercoagulable state induced by AML and the resultant NBTE, leading to recurrent embolic strokes, despite oral anticoagulation. This case contributes to the scientific literature by highlighting the diagnostic and therapeutic challenges in managing NBTE in patients with hematologic malignancies. The patient had multiple ED visits, initially with concerns of persistent back spasms, and was diagnosed with venous thromboembolism and started on apixaban. She then returned to our ED with visual disturbances and headaches. Significant clinical findings included right hemianopsia and circulating blasts on laboratory tests, indicative of AML relapse. Imaging studies revealed multiple small acute cerebral infarctions and evidence of thrombus affecting the mitral and aortic valves. The patient was diagnosed with NBTE and treated with systemic anticoagulation using warfarin, bridged with enoxaparin sodium. She remained stable during hospitalization and was discharged with follow-up care coordinated among her oncology, neurology, and cardiology teams. NBTE is an important consideration in a differential diagnosis in patients with cancer causing a hypercoagulable state such as AML, particularly in patients who present with neurological symptoms. High index of suspicion and a multidisciplinary approach are essential for the timely diagnosis and management of NBTE to prevent further thromboembolic complications.
非细菌性血栓性心内膜炎（NBTE）是一种罕见但严重的并发症，尤其是在患有急性髓系白血病（AML）等恶性肿瘤的患者中，高凝状态会增加栓塞事件的风险。本病例报告描述了一名78岁复发性AML女性患者罕见且复杂的消耗性心内膜炎表现。该病例的独特之处在于AML诱导的高凝状态与由此产生的NBTE相互交织，尽管进行了口服抗凝治疗，仍导致复发性栓塞性中风。本病例通过强调血液系统恶性肿瘤患者管理NBTE时的诊断和治疗挑战，为科学文献做出了贡献。该患者多次到急诊就诊，最初担心持续的背部痉挛，被诊断为静脉血栓栓塞，并开始服用阿哌沙班。然后她因视力障碍和头痛再次回到我们的急诊室。重要的临床发现包括右侧偏盲和实验室检查发现循环原始细胞，提示AML复发。影像学研究显示多发性小的急性脑梗死以及影响二尖瓣和主动脉瓣的血栓证据。该患者被诊断为NBTE，并使用华法林进行全身抗凝治疗，同时用依诺肝素钠进行桥接治疗。她在住院期间保持稳定，出院时由肿瘤学团队、神经学团队和心脏病学团队协调后续护理。在导致高凝状态的癌症患者如AML中，NBTE是鉴别诊断中的一个重要考虑因素，特别是在出现神经系统症状的患者中。高度的怀疑指数和多学科方法对于NBTE的及时诊断和管理至关重要，以防止进一步的血栓栓塞并发症。
