Treatment with a Direct Oral Anticoagulant for Nonbacterial Thrombotic Endocarditis

Abstract

We herein report a case of nonbacterial thrombotic endocarditis (NBTE) in a patient with previously undiagnosed lung cancer. A 62-year-old woman presented to our hospital with multiple cerebral infarctions. There was no evidence of valvular heart disease or vegetations. Whole-leg ultrasonography revealed deep vein thrombosis of the left peroneal vein. We administered direct oral anticoagulants (DOACs) for a presumed diagnosis of paradoxical embolisms caused by patent foramen ovale. Unfortunately, she experienced further embolization and died. At a postmortem examination, she was diagnosed with NBTE and metastatic adenocarcinoma of the lung. Our experience with this patient suggests that DOACs may be an insufficient treatment for NBTE.

Keywords: direct oral anticoagulants; echocardiography; lung cancer; nonbacterial thrombotic endocarditis; postmortem.

Figure 1.

A: Computed tomography shows a 10-mm nodular lesion in the right lung (arrow). B, C: Diffusion-weighted magnetic resonance imaging demonstrates multiple cerebral infarctions (arrowheads).

Figure 2.

A, B: Transesophageal echocardiography on admission shows only trivial aortic regurgitation (yellow arrows) without vegetations. C, D: Transesophageal echocardiography on day 24 demonstrates moderate aortic regurgitation (yellow arrow) and vegetations on the noncoronary and left coronary cusps of the aortic valve (white arrows).

Figure 3.

A: Many vegetations are seen on the aortic leaflets (arrowheads). B: Histopathologic section of the vegetations reveals no visible evidence of microorganisms. C: A histopathologic examination of the right lung mass reveals adenocarcinoma. D: The left lung contains a metastatic adenocarcinoma lesion (arrowheads).