Multidisciplinary Approach in Libman-Sacks Endocarditis

Libman-Sacks endocarditis is a noninfectious form of endocarditis associated with systemic lupus erythematosus (SLE), antiphospholipid antibody syndrome (APS), and solid malignancies.

A 20-year-old woman with no medical history presented with left-sided weakness and facial drooping. Laboratory tests were unremarkable except for thrombocytopenia and a prolonged activated partial thromboplastin time. Brain magnetic resonance imaging revealed an acute ischemic infarct in the bilateral frontal lobes. A transthoracic echocardiogram (TTE) and subsequent transesophageal echocardiogram (TEE) identified two mitral vegetations with regurgitation: the first located on the posterior leaflet with perforation (1.2 × 1.0 cm) and the second (1.0 × 0.9 cm) situated on the subvalvular apparatus of the anterior leaflet. The patient reported no signs of infection, and multiple blood cultures showed no bacterial growth. A rheumatological panel indicated SLE and APS, which resulted in a diagnosis of Libman-Sacks endocarditis. The patient received treatment with Coumadin and hydroxychloroquine, and a surgical resection of the vegetation was scheduled if the valvular lesions did not resolve within 1 month. However, a follow-up TTE demonstrated near-complete resolution of the masses.

A stroke in a young individual should raise suspicion for Libman-Sacks endocarditis. Due to limited evidence regarding surgical versus conservative management, a multidisciplinary approach is recommended. This case illustrates the successful conservative management of two large vegetations.