Rapid Review·Cardiovascular
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Inflammatory & Infective Disease
T1Must knowNonbacterial Thrombotic Endocarditis
Focus on
Sterile platelet-fibrin vegetations that embolize in a patient with advanced cancer (marantic) or lupus/antiphospholipid syndrome (Libman-Sacks). Negative cultures, no fever, a stroke or a cold limb out of nowhere; treat with heparin and the underlying disease.
Key takeaways
What it is
Nonbacterial thrombotic endocarditis
non-infectious endocarditis with sterile thrombi deposited on the valves.Two settings
advanced malignancy ("marantic" endocarditis) and systemic lupus erythematosus ("Libman-Sacks" endocarditis).
What this shows
Libman-Sacks vegetations
verrucous, sitting on both sides of the valve, in lupus or the antiphospholipid syndrome.Clinical features
Silent until it embolizes
usually no symptoms until an arterial embolus hits the kidney, spleen, skin, limbs or brain.Embolization is common
the vegetations dislodge easily, with hemorrhages under the nails, in the skin and in the retina.What is usually missing
fever, leukocytosis and a significant regurgitant murmur are uncommon, unlike Infective Endocarditis.Diagnosis and management
Blood cultures
must be negative.Transthoracic echocardiography
shows small, mobile, sterile vegetations on the valve surface.Look for the driver
a malignancy or a hypercoagulable state, depending on the patient.Management
anticoagulation with heparin; surgery if complications arise.| Nonbacterial thrombotic | Infective | |
|---|---|---|
| Fever and leukocytosis | Uncommon | Common |
| Significant regurgitant murmur | Uncommon | A new regurgitant murmur is typical |
| Blood cultures | Negative | Positive |
| Main treatment | Heparin | Weeks of intravenous antibiotics |
A woman with metastatic pancreatic cancer suddenly develops a left hemiparesis; she has no fever, echo shows small mobile mitral vegetations, and three sets of blood cultures are sterile. What is the diagnosis and the treatment?
Nonbacterial thrombotic (marantic) endocarditis: sterile thrombi on the valve that embolize easily, with negative cultures and no fever. Treat with anticoagulation (heparin) and the underlying disease; surgery only if complications arise.
How it's tested
A woman with metastatic pancreatic cancer has a sudden left hemiparesis; echo shows small mitral vegetations and three sets of blood cultures are sterile: marantic (nonbacterial thrombotic) endocarditis — heparin.
A 30-year-old with SLE and antiphospholipid antibodies presents with a TIA; TEE shows verrucous vegetations on both sides of the mitral leaflets: Libman-Sacks endocarditis — anticoagulation plus lupus therapy.
How to distinguish it from infective endocarditis: no fever, no leukocytosis, negative cultures, small non-destructive vegetations; embolism is the presentation.
Multiple small infarcts in different vascular territories on brain MRI in a cancer patient: cardioembolic — look at the valves.
Go deeper
Related Step 2 pages: Infective Endocarditis, Mitral Regurgitation, Acute Limb Ischemia
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