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case_images: (a) Tranesophageal echocardiogram (TEE). Large mass attached to the aortic valve (yellow arrow). Small mass attached to the anterior mitral leaflet (red arrow) and (b) TEE color Doppler shows severe aortic regurgitation.
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case_images: The TEE showed multiple highly mobile, irregular shape masses attached to right and left coronary cusps of the aortic valve, largest mass measuring 20 x 18 mm2 with eccentric severe aortic regurgitation, no associated abscess or fistula, similar echogenicity mass attached to anterior mitral valve measures 7 x 4 mm2, and posterior mitral valve mass measures 5 x 3 mm2, and there was mild mitral regurgitation and no intracardiac shunt (Figure 1(a) and (b)).
case_images: (a) Magnetic resonance imaging (MRI) of brain: (a) bilateral occipital acute ischemic stroke and (b) bilateral parietal acute ischemic stroke.
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case_images: Magnetic resonance imaging (MRI) of the brain (Figure 2(a) and (b)) revealed multifocal diffusion restrictions involving bilateral high frontal and left thalamus, bilateral occipital lobes, and bilateral cerebellar hemispheres, with no significant mass effect.
case_images: Computed tomography (CT) of the abdomen showing the hypovascular liver mass.
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case_images: The follow-up investigations of all the tests performed on the patient leads to the following conclusions: (1) all blood cultures were negative; (2) Brucella titer and serology for Q fever were negative; (3) markers for tumors came back positive (CA-125 102 U/mL, CA19-9 5247 U/mL, CEA 13.6 U/mL); (4) thrombophilic evaluation, including anti-nuclear antibody (ANA), anti-neutrophil cytoplasmic antibody (ANCA), antiphospholipid antibodies (cardiolipin IgG and IgM), Factor-V Leiden mutation, homocysteine, Protein-S, Protein-C and Antithrombin-III levels, was unremarkable; and (5) CT scan of chest, abdomen and pelvis unveiled the presence of hypovascular hepatic mass having dimensions of 7.8 x 5.7 x 6.4 cm3, which invaded the right portal vein as well as the right hepatic duct with multiple porta hepatis and retroperitoneal lymphadenopathies, thereby leading to an alarming stage of cholangiocarcinoma (Figure 3).
case_images: (a) The photomicrographs show a normal liver tissue (A) exhibiting a tumor formed of cells arranged in glands and tubules, the tumor cells display hyperchromatic pleomorphic nuclei (B) with increased mitotic activity, the tumor is surrounded by desmoplastic stroma and (b) the tumor showed positive immunohistochemical reaction for CytoKeratin7 (CK7). The above-mentioned features are in keeping with cholangiocarcinoma.
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case_images: The patient underwent ultrasound-guided liver biopsy showed well-differentiated adeno-carcinoma, consistent with the diagnosis of cholangiocarcinoma (Figure 4(a) and (b)).
case_images: (a) The follow-up transthoracic echocardiogram showing small calcified aortic mass and no mass on the mitral valve and (b) color Doppler showing mild aortic regurgitation.
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case_images: The follow-up transthoracic echocardiogram after 10 days of admission showed the presence of a small calcified aortic valve mass, which measures 6 x 4 mm2, mild aortic and mitral regurgitation and no evidence of mitral valve mass (Figure 5(a) and (b)).