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Author Spotlight: Assessing Ischemic Stroke Damage Through Middle Cerebral Artery Occlusion Model
Published on: August 11, 2023
Multi-territory stroke preceded by pulmonary embolism with asymptomatic coronavirus disease 2019: a case report
Jakob Van Herck1,2, Hendrik Thoen1,3, Christophe Delens1
1Department of Cardiology, General Hospital AZ Nikolaas, Moerlandstraat 1, 9100 Sint-Niklaas, Belgium.
Insights
Non-bacterial thrombotic endocarditis can cause strokes and may indicate prostate cancer. Elderly patients with venous thromboembolism, even after COVID-19, should be screened for malignancy. This rare condition highlights the link between cancer and embolic events.
Area of Science:
- Cardiology
- Neurology
- Oncology
Background:
- Non-bacterial thrombotic endocarditis (NBTE) involves sterile vegetations on heart valves.
- NBTE is a rare cause of embolic events, including stroke.
Observation:
- A 66-year-old male presented with multi-territory stroke and pulmonary embolism.
- Initial pulmonary embolism was attributed to asymptomatic COVID-19, but NBTE of the aortic valve was diagnosed.
- Elevated prostate-specific antigen led to the diagnosis of metastatic prostate adenocarcinoma.
Findings:
- NBTE on the aortic valve caused embolic stroke.
- Prostate cancer was identified as the underlying malignancy, leading to paraneoplastic pulmonary embolism.
- Treatment of prostate cancer resolved the aortic valve vegetations.
Implications:
- COVID-19 alone may not be sufficient to cause venous thromboembolism in ambulatory patients.
- Elderly patients with thromboembolic events require thorough malignancy screening.
- Prostate cancer should be considered in cases of NBTE presenting as stroke.
Background:
Non-bacterial thrombotic endocarditis is characterized by the presence of sterile vegetations on a cardiac valve. We present a case of multi-territory stroke caused by embolism of a non-bacterial thrombotic aortic valve endocarditis, leading to the diagnosis of a prostate adenocarcinoma with bone metastases.
Case Summary:
A 66-year-old patient was diagnosed with pulmonary embolism, first attributed to an asymptomatic coronavirus disease 2019 infection. Edoxaban was started, which was discontinued by the patient. Four weeks later, he presented with subacute vertigo and balance disorders. Magnetic resonance imaging showed a multi-territory stroke. A transoesophageal echocardiogram demonstrated a small vegetation on the aortic valve with moderate aortic insufficiency. Blood cultures remained negative. Malignancy screening showed a markedly elevated prostate-specific antigen. Prostate adenocarcinoma was confirmed on biopsy. A positron emission tomography revealed metastatic disease. A diagnosis of non-bacterial thrombotic endocarditis and paraneoplastic pulmonary embolism secondary to prostate cancer was made. Edoxaban was restarted and the patient was referred for treatment of the prostate adenocarcinoma. Follow-up after 5 months showed no evidence of aortic valve vegetations.
Discussion:
Coronavirus disease 2019 in ambulatory patients may be insufficient as a predisposing factor for venous thrombo-embolism and these patients, especially the elderly, should undergo a screening for malignancy. Non-bacterial thrombotic endocarditis is a rare cause of multi-territory stroke. When related to cancer, the prostate can be the primary tumour.
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