Marantic endocarditis and paraneoplastic pulmonary embolism

Abstract

Cancer is frequently associated with a hypercoagulable state. Almost 15% of patients with cancer will suffer a thromboembolic event during their clinical course. The aetiology of this hypercoagulable state is multifactorial and includes procoagulant factors associated with malignancy as well as the host's inflammatory response. Cancer-associated thrombophilia can present as venous thromboembolism, migratory superficial thrombophlebitis, arterial thrombosis, disseminated intravascular coagulation, thrombotic microangiopathy and rarely non-bacterial thrombotic endocarditis (NBTE). In this paper, we will describe an uncommon presentation of lung cancer on a non-smoker middle-aged woman, with recent diagnosis of pulmonary embolism, who develops malignant recurrent pleural effusion, NBTE with cutaneous and neurological manifestations, with a rapid evolution into shock, culminating in death. Diagnosis of NBTE requires a high degree of clinical suspicion. The mainstay of treatment is systemic anticoagulation to prevent further embolisation and underlying cancer control whenever is possible.

Keywords: lung cancer (oncology); pulmonary embolism; stroke; valvular diseases; venous thromboembolism.

Figure 1

Right-side pleural effusion on chest CT scan.

Figure 2

Splinter haemorrhage under the nail.

Figure 3

Aortic valve vegetation on transoesophageal echocardiography (TEE) (indicated with arrow).

Figure 4

Aortic valve vegetation with moderate to severe regurgitation on transoesophageal echocardiography (TEE) (indicated with arrow and star, respectively).