SPC365

The thrombotic puzzle: unmasking a cancer of unknown primary origin

Session: Casos Clínicos: Insuficiência Cardíaca e Cuidados Intensivos Cardíacos
Speaker: Jéni Quintal

Congress: CPC 2024
Topic: D. Heart Failure
Theme: 10. Chronic Heart Failure
Subtheme: 10.6 Chronic Heart Failure - Clinical
Session Type: Sessão de Casos Clínicos
FP Number: ---
Authors: Jéni Quintal; Joana Silva Ferreira; David Prescott; Rui Antunes Coelho; Catarina Pohle; Tatiana Duarte; Sara Gonçalves; Isabel Silvestre; Filipe Seixo

<p style="text-align:justify"><span style="font-size:12pt"><strong><span style="font-size:10.0pt"><span style="color:black">Background:</span></span></strong> <span style="font-size:10.0pt"><span style="color:black">Marantic endocarditis (ME) associated with cancer is rare. Lung adenocarcinoma (LADC) is the prevailing subtype. Systemic embolization manifests in more than 80% of ME, impacting more often brain, lung, spleen, kidney and extremities. However, metastatic LADC (M-LADC) in this subset is even rarer and carries a dismal prognosis.</span></span></span></p>

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<p style="text-align:justify"><span style="font-size:12pt"><strong><span style="font-size:10.0pt"><span style="color:black">Case report:</span></span></strong><span style="font-size:10.0pt"><span style="color:black"> A 59-years-old male with hypertension, dyslipidemia and type 2 diabetes is admitted in emergency room with 2-days evolution complaints of fatigue and dyspnea on exertion and syncope 1h prior. Physical examination revealed bi-basal crackles, louder in the right lung. EKG showed q waves and </span></span><span style="font-size:10.0pt"><span style="color:black">=</span></span><span style="font-size:10.0pt"><span style="color:black">1mm ST elevation in inferior leads. Arterial blood gas analysis showed respiratory alkalemia and mild hypoxemia. Blood (Bl) tests were notable for elevated D-dimers, high-sensitivity troponin-I (TnI) and NT-proBNP.</span></span></span></p>

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<p style="text-align:justify"><span style="font-size:12pt"><span style="font-size:10.0pt"><span style="color:black">Inferior subacute STEMI and pulmonary embolism (PE) were suspected. </span></span><span style="font-size:10.0pt"><span style="color:black">Transthoracic echocardiogram (TTE) showed mild to moderate left ventricular dysfunction (LVEF 40-44%) with inferior and inferolateral wall hypokinesia (HK), mild to moderate mitral and aortic regurgitations (AR) and right-sided mild to moderate pericardial effusion (PE). A chest CT confirmed PE and a brain-CT showed an old right frontal subcortical ischemic infarction. Coronary angiography showed middle circumflex artery occlusion obliging angioplasty. </span></span></span></p>

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<p style="text-align:justify"><span style="font-size:12pt"><span style="font-size:10.0pt"><span style="color:black">During in-hospital stay, he evolved into class II of Killip. Triple antithrombotic therapy was started but later de-escalated to double due to hematuria. At discharge time, he kept LV dysfunction with segmentary HK and valvular regurgitations; PE improved. He was referred to heart failure (HF) and angioplasty appointments.</span></span></span></p>

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<p style="text-align:justify"><span style="font-size:12pt"><span style="font-size:10.0pt"><span style="color:black">Readmitted 48h later for sudden onset of general malaise and altered state of consciousness, TTE showed moderate to severe AR, Bl tests elevated TnI and NT-proBNP and brain-CT multiple recent vascular lesions.</span></span></span></p>

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<p style="text-align:justify"><span style="font-size:12pt"><span style="font-size:10.0pt"><span style="color:black">Transesophageal echo confirmed severe AR due to cusp central noncoaptation. The cusps were thickened with a nodular infiltration aspect, raising ME suspicion. Empiric antibiotics were started. We requested Bl cultures, PET, autoimmunity, thrombophilia and occult neoplasia studies. PET revealed supra-diaphragmatic and pelvic ganglionic and osteo-medullary radiopharmaceutical uptake, as well as a large circumferential PE. The patient progressed to cardiac tamponade requiring urgent pericardiocentesis. PE cells were positive for CK7+ and TTF1+, favoring M-LADC, later confirmed by lymph node biopsy. Discharged after 40 days, he continued anticoagulation (ACO) and was referred to oncology.</span></span></span></p>

<p style="text-align:justify"><span style="font-size:12pt"><span style="font-size:10.0pt"><span style="color:black"><strong>Conclusion</strong>: This is a complex and rare case of ME linked to metastatic lung adenocarcinoma, manifested with multiple embolic events (EE). Marantic endocarditis in this context has a very poor prognosis and its diagnosis should be considered when new valvular regurgitations accompany EE.</span></span></span></p>