Non-infectious thrombotic endocarditis
The above image refers to an autopsied case of a 66-year-old woman hospitalized due to marked asthenia, dyspnea, edema, and jaundice. She had a past medical history of hypertension and hypothyroidism, and recently she had been diagnosed with a combined lesion of the aortic valve (predominantly stenosis) and heart failure. A laboratory work-up revealed a peak systolic pressure gradient across the aortic valve of 110 mm Hg, concentric ventricular hypertrophy, and a mobile and filamentary vegetation attached to the atrial surface of the mitral valve measuring 15 × 10 mm, elevated bilirubin, hepatic enzymes, and altered coagulation tests. The patient was screened for viral hepatitis and autoantibodies, which resulted in a positive ANA titer 1/320 speckled pattern. The patient was referred to a tertiary cardiology center with the working diagnosis of infective endocarditis. Blood cultures were repeatedly negative. The outcome was unfavorable with worsening of the respiratory function then death.
The autopsy showed an extensive venous thrombosis of the right iliac vein accompanied by great vessel pulmonary embolism with extensive infarction areas. The authors infer the possibility of a thrombophilia associated with an indeterminate autoimmune disease, which could explain the thromboembolic phenomena and the presence of NBTE. It is possible that the mitral valve’s vegetation detected on the Doppler examination detached by the time the autopsy was done and could not be found.