Tuberculosis-associated nonbacterial thrombotic endocarditis: A case report

A 69-year-old man with chronic hematuria suddenly presented with left hemiplegia. Brain magnetic resonance imaging revealed multiple infarctions, suggesting possible cardiac involvement, and echocardiography detected a 5-mm vegetation on the aortic valve. A systemic computed tomography showed tree-in-bud opacities in the left lung and bladder wall thickening, and polymerase chain reaction testing and mycobacterial culture identified Mycobacterium tuberculosis (TB) in sputum and urine. Mycobacterial blood culture and histopathology of the intracranial thrombus were negative for tuberculosis, and the overall findings supported a diagnosis of TB-associated nonbacterial thrombotic endocarditis (NBTE). Following the initiation of standard anti-TB therapy in combination with a direct oral anticoagulant agent, the patient remained clinically stable and experienced no further embolic events. NBTE is most commonly associated with malignancy or autoimmune disease and only rarely arises from an infectious etiology. TB-associated NBTE is exceptionally rare, and its diagnosis remains highly challenging even with advanced diagnostic modalities.