Non-Bacterial Thrombotic Endocarditis in a Patient with Rheumatoid Arthritis

Abstract

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.

Keywords: Arthritis, rheumatoid; Endocarditis, non-infective; Mitral valve.

Fig. 1. Mitral valve vegetation. (A, B) Transthoracic echocardiography showing a 0.27×2.27 cm sized characteristic hyperechoic mass-like nodular lesion (NBTE, arrow) attached to the posterior cusp of the mitral valve. This lesion had a stem connecting the mass to the mitral valve, causing the lesion to show a to and fro motion in accordance with the cardiac cycle. (C, D) After 4 weeks of anticoagulation therapy, the NBTE lesion disappeared almost completely on echocardiography. NBTE: nonbacterial thrombotic endocarditis.

Fig. 2. Brain magnetic resonance image. The arrow indicated the location of multifocal cerebellar (A: diffusion weighted image, B: diffusion weighted image) and cerebral infarctions (C: T2 weighted image).