A woman in her 60s with confusion

Delirium is common in patients admitted to hospital, and may sometimes be the first sign of a serious underlying condition. Identifying a specific cause can be complex, especially in patients without clear precipitating factors.

A woman in her sixties was admitted to hospital with neurological symptoms and acute confusion. Delirium of unknown origin was suspected. Blood tests revealed elevated troponins and ECG showed subtle ST changes, but she reported no chest pain. CT revealed infarctions in the kidney and spleen, and brain MRI showed multiple embolic infarctions. Despite negative blood cultures and absence of other signs of infection, bacterial endocarditis was suspected, and empirical antibiotics were started. Transthoracic echocardiography was initially inconclusive, and transoesophageal echocardiography (TEE) was not feasible due to her cognitive state. PET-CT showed pathological FDG uptake in cervical lymph nodes, and biopsy revealed metastatic adenocarcinoma. As her delirium gradually improved, TEE revealed aortic valve vegetations. Cardiac MRI demonstrated embolic myocardial infarction.

With a negative infectious workup and confirmed malignancy, the diagnosis of non-bacterial thrombotic endocarditis was established. Anticoagulation with low-molecular-weight heparin was initiated. This case highlights the importance of a broad diagnostic approach in delirium when initial evaluation does not reveal a clear cause.