Trousseau's syndrome with non-bacterial thrombotic endocarditis (NBTE) in a patient with advanced pancreatic cancer.

Non-bacterial thrombotic endocarditis (NBTE), or marantic endocarditis, is a rare condition frequently associated with advanced malignancy. It is diagnosed by presence of valvular vegetations without evidence of valve destruction and bacteraemia. We present a case of Trousseau's syndrome, also known as migratory superficial thrombophlebitis, with NBTE after diagnosis of advanced pancreatic cancer. A 62-year-old man presented with a 1-week history of swollen and painful right leg. Ultrasound doppler confirmed great saphenous vein superficial thrombophlebitis and prophylactic low molecular weight heparin (LMWH) was commenced. On examination, there was also a pan-systolic murmur, but no peripheral stigmata of infective endocarditis (IE). He demonstrated bilateral nystagmus at extremes of gaze but no other focal signs and computed tomography (CT) head ruled out acute intracranial abnormality. Elevated troponin prompted CT pulmonary angiogram (CTPA) which ruled out pulmonary embolism, but found a pancreatic tail lesion, later confirmed as pancreatic adenocarcinoma with liver metastases. He re-presented few days later with fever, abdominal pain, transient expressive dysphasia and left sided visual loss. His clinical examination revealed new splinter haemorrhages and left sided inferior homonymous quadrantanopia. CT showed acute splenic and left renal infarcts, as well as multiple embolic infarcts to right occipital, right thalamic and cerebellar (Fig 1). Procalcitonin was normal and three sets of peripheral blood cultures were negative. Transthoracic echocardiogram (TTE) did not show vegetations, however transoesophageal echocardiogram (TOE) demonstrated two masses on the aortic valve with central jet of aortic regurgitation (Fig 2). Given diagnosis of pancreatic malignancy, multiple emboli, negative blood cultures and valvular vegetations without evidence of valve destruction, the clinical presentation was consistent with Trousseau's syndrome with NBTE. He was commenced on split treatment dose LMWH. Our case highlights the diagnostic challenges associated with Trousseau's syndrome and NBTE ante-mortem. Vegetations in NBTE are usually small and irregularly shaped which can be missed on TTE. Vegetations can also have embolised resulting in normal echocardiography. Clinicians should not be falsely reassured by normal TTE and proceed with TOE if there is high clinical suspicion of NBTE. Treatment for IE and NBTE differs significantly. Blood cultures are needed to rule out IE; however, culture-negative IE or negative cultures taken after antibiotics should be considered. The mainstay treatment for IE is antibiotics and given the high risk of mycotic aneurysm rupture, anticoagulation therapy must be carefully weighed in patients with possible intracerebral septic emboli.1 Whereas treatment for NBTE is therapeutic anticoagulation while addressing underlying malignancy. Anticoagulation therapy should be a multidisciplinary decision after weighing up the risk versus benefits alongside management of the underlying malignancy. Our case demonstrates that multiple thromboembolic events in the presence of active malignancy, should prompt investigations of NBTE. Early diagnosis and treatment are critical in reducing complications of thromboembolic disease and allow prompt initiation of oncological treatment. [ABSTRACT FROM AUTHOR]