A 51-year-old woman with no relevant past medical history was admitted for stroke with dysnomia and right paresis, with multiple ischemic foci detected by scanner and magnetic resonance imaging, suggesting embolic origin.
On admission, she had plantar afferent response, with blood pressure 120 mmHg, shedding light on neurological examination, reduced verbal fluency with paraphasias, right central facial, right brachio-crural motor deficit and one right.
Systemic examination was normal except petechiae in the tibial region of the right lower extremity and hemorrhages in hands with several fingers of both hands.
Blood tests were normal except for an increase in acute phase reactants.
The electrocardiogram, transcranial Doppler, continuous carotid Doppler and eye fundus were normal.
Cardiac, transthoracic, and transesophageal echography showed a patent foramen ovale (MRA) and a mild septal defect (MI) of 15 millimeters over the posterior leaflet of the mitral valve with mitral regurgitation (MR).
With the suspicion of subacute bacterial endocarditis, empirical antibiotic treatment with Vancomycin and Gentamicin was initiated prior to the extraction of hemocultives. The patient was afflicted during hospitalization.
A chest X-ray showed a nodule in the left lower lobe (LII), which was later confirmed in a scanner as a 3.5 centimeter mass in LII, satellite nodules, lymph node lymph node adenopathies contralateral carcinoma.
Seven days after the start of antibiotic treatment, after knowing the negative culture results, a control echocardiogram was performed in the patient with newly diagnosed endocarditis K. See differential diagnosis for hemoidella (9.1 mm) and chculias,
On the 8th day of the beginning of the treatment, the patient presented nonspecific pain in the left hypochondrium. An abdominal ultrasound was performed, with the suspicion of splenic embolism and no pathology was found.
On the 9th day, the patient developed syncope in the context of a transient ischaemic attack (transient weakness of the left upper limb).
On the 11th day she presented a significant clinical deterioration due to ictal symptoms with total involvement of the anterior circulation of the left middle cerebral artery (global, visual impairment and right hemiplegia).
The control echocardiogram showed progression of previous lesions and new mitral stenosis in the atrial face.
Given the poor clinical and echocardiographic evolution, the diagnosis of NBTE is proposed, performing a biopsy of the lung mass, which is an adenocarcinoma.
Treatment was started with intravenous heparin (iv.i.) given the association of NBTE and hypercoagulability, the onset of disseminated coagulation (DIC) with increased fibrinogen and PDF.
The hypercoagulability studies, markers of cryoglobulinemia, antiphospholipid antibodies HIV, HBV, HCV and ANA were negative, as well as the 12 blood samples and the different serologies mentioned above.
The age, sex of the patient and the presence of high CA 12.5 and CA 15.3 tumor markers led us to search for primary adenocarcinoma of the breast and ovary without finding any findings.
There was no clinical improvement and radiological worsening despite the initiation of treatment with intravenous heparin.
The patient was diagnosed with stage IV adenocarcinoma of the lung with embolus formations in the context of paraneoplasia.
The situation of the patient with PS4 contraindicated any chemotherapy treatment with intent, except for palliative symptomatic treatment.
In this context, the patient is referred to a Palliative Care Unit.
