A 51-year-old woman with no previous history of interest was admitted for stroke with dysnomia and right paresis, with multiple ischaemic foci demonstrated by scanner and magnetic resonance imaging, suggesting embolic origin.
On admission he was afebrile, with blood pressure 120/60 mmHg, and on neurological examination he had reduced verbal fluency with frequent paraphasias, right central facial, a right brachio-crural motor deficit and an indifferent right plantar response. The systemic examination was normal except for petechiae in the tibial region of the right lower extremity and splinter haemorrhages in several fingers of both hands.
Laboratory tests were normal except for an increase in acute phase reactants. Electrocardiogram, transcranial Doppler, continuous carotid Doppler and fundus examination were normal. Transthoracic and transesophageal cardiac ultrasound showed a patent foramen ovale, mitral prolapse and a 15 mm wart on the posterior leaflet of the mitral valve with mild mitral insufficiency (MI). With the suspicion of subacute bacterial endocarditis, empirical antibiotic treatment was started with Vancomycin and Gentamicin after blood cultures had been taken, the patient being afebrile, a situation in which she remained during admission.
The chest X-ray showed a nodule in the left lower lobe (LII) which was later confirmed by scanner as a 3.5 centimetre mass in LII, satellite nodules, contralateral lymphadenopathy and carcinomatous lymphangitis suggestive of a neoplastic process.
Seven days after the start of antibiotic treatment, after learning of the negative results of the cultures, a control echocardiogram was performed in which the appearance of a new wart (5.7 mm) and a decrease in size of the previous wart (9.1 mm) was observed. New blood cultures were performed to emphasise the differential diagnosis of endocarditis with negative cultures (HACEK, fungi) and serologies for Legionella, Bartonella, Coxiella, Chlamydia, Mycoplasma...
On the 8th day after starting treatment, she presented with non-specific pain in the left hypochondrium, and an abdominal ultrasound was performed with the suspicion of splenic embolism, but no pathology was found.
On the 9th day he presented a syncopal picture in the context of a transient ischaemic accident (transient weakness of the left upper limb).
On the 11th day he presented a significant clinical deterioration due to ictal symptoms with total involvement of the anterior circulation of the left middle cerebral artery (global aphasia, visual inattention and right hemiplegia). The control echocardiogram showed progression of the previous lesions and a new wart on the atrial side of the mitral valve.
Given the poor clinical and echocardiographic evolution, a diagnosis of ETNB was made and a biopsy of the pulmonary mass was performed, this being an adenocarcinoma. Treatment with intravenous (IV) heparin was started due to the association of NBTE and hypercoagulability, and the onset of disseminated intravascular coagulation (DIC) was observed, with increased fibrinogen and PDF
Hypercoagulability studies, cryoglobulinaemia, antiphospholipid, HIV, HBV, HCV and ANA markers were negative, as were the 12 blood culture samples and the various serologies mentioned above.
The patient's age, sex and the presence of high tumour markers CA 12.5 and CA 15.3 led us to search for primary adenocarcinoma in the breast and ovary, but no findings were found.
There was no clinical improvement and radiological worsening despite treatment with i.v. heparin.
The patient was diagnosed with stage IV adenocarcinoma of the lung with emboligenic phenomena in the context of paraneoplasia. The patient's situation with a PS4 contraindicated any chemotherapy treatment with palliative intent, being only subsidiary to palliative symptomatic treatment. In this context, the patient was transferred to the Palliative Care Unit.