Nonbacterial Thrombotic Endocarditis
A previously healthy 48-year-old man presented to the emergency department with acute onset of pain in both flanks. During the preceding 6 months he had had an unintentional weight loss of approximately 5 kg. Numerous splinter hemorrhages were observed on the fingernails of both hands (Panel A). No cardiac murmur was heard, but the abdomen was tender and the spleen was palpable below the left costal margin. Blood cultures were drawn, and antibiotic treatment was initiated for suspected bacterial endocarditis. A transesophageal echocardiogram showed mobile echogenic foci on the tricuspid and mitral valves. Computed tomography of the abdomen revealed a mass in the neck of the pancreas, multiple liver lesions, and multiple hypodensities in the spleen and kidneys, which were consistent with infarcts (Panel B). Examination of a biopsy specimen of a liver lesion revealed pancreatic adenocarcinoma. Blood cultures and serologic tests for organisms known to cause culture-negative infective endocarditis were negative. A diagnosis of nonbacterial thrombotic endocarditis associated with metastatic pancreatic cancer was made. Anticoagulation therapy with low-molecular-weight heparin was initiated, as was chemotherapy. The patientโs flank pain, peripheral stigmata of endocarditis, and cardiac-valve thrombi resolved. However, 7 months after diagnosis, he died from complications of progressive pancreatic cancer.