Systemic thromboembolism from a misdiagnosed non‑bacterial thrombotic endocarditis in a patient with lung cancer: A case report

Perrone,Fabiana; Biagi,Andrea; Facchinetti,Francesco; Bozzetti,Francesca; Ramelli,Andrea; Vezzani,Antonella; Manca,Tullio; Gnetti,Letizia; Majori,Maria; Alfieri,Veronica; Tiseo,Marcello

doi:10.3892/ol.2020.12056

Systemic thromboembolism from a misdiagnosed non‑bacterial thrombotic endocarditis in a patient with lung cancer: A case report

Authors:
- Fabiana Perrone
- Andrea Biagi
- Francesco Facchinetti
- Francesca Bozzetti
- Andrea Ramelli
- Antonella Vezzani
- Tullio Manca
- Letizia Gnetti
- Maria Majori
- Veronica Alfieri
- Marcello Tiseo
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Affiliations: Medical Oncology Unit, University Hospital of Parma, I-43126 Parma, Italy, Cardiology Department, University Hospital of Parma, I-43126 Parma, Italy, Department of Neuroradiology, University of Parma, I-43126 Parma, Italy, Cardiac Surgery Intensive Care Unit, University of Parma, I-43126 Parma, Italy, Unit of Pathology, University of Parma, I-43126 Parma, Italy, Unit of Pulmonology and Thoracic Endoscopy, University of Parma, I-43126 Parma, Italy, Unit of Respiratory Disease and Lung Function, University of Parma, I-43126 Parma, Italy
Published online on: September 3, 2020 https://doi.org/10.3892/ol.2020.12056
Article Number: 194
Copyright: © Perrone et al. This is an open access article distributed under the terms of Creative Commons Attribution License.

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Abstract

Thromboembolic events are frequent in patients with cancer, commonly involving the venous and pulmonary circulation. The arterial system is rarely implicated in embolism and, when involved, a cardiogenic origin should always be excluded. In the present study, a case of a patient who developed multiple embolic events concomitantly with the diagnosis of locally‑advanced non‑small cell lung cancer with high expression levels of programmed death‑ligand 1 (PD‑L1) in >50% of tumor cells is reported. A cardiac defect interpreted as a patent foramen ovale required low molecular weight heparin administration. Despite the anti‑coagulant therapy, before first‑line anticancer treatment with pembrolizumab immunotherapy could be administered due to high PD‑L1 expression levels, a new hospitalization was required due to the onset of novel ischemic manifestation. New transthoracic and transesophageal echocardiography revealed a previously misdiagnosed vegetation of the mitral valve that caused systemic embolization. The lack of any sign of infection led to the diagnosis of a non‑bacterial thrombotic endocarditis (NBTE), whose embolic sprouting gave rise to the widespread ischemic events. No active anticancer treatment was feasible due to the rapid progression of the disease. NBTE can evolve quickly, eventually preventing any chance of treatment targeting the primary cause, which in the present study was lung cancer. If NBTE can be correctly diagnosed sooner then there may be the potential for anticancer therapy that does not worsen the hypercoagulability state, thus improving cancer‑associated survival.

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