Recurrent Strokes as the First Presentation of Occult Pancreatic Cancer; Trousseau Syndrome: A Case Report

Cerebrovascular disorders (CVDs) are widespread in cancer patients, exacerbating their condition and lowering their prognosis. Approximately 15% of cancer patients have a coexisting CVD. Stroke may occur after the initial cancer diagnosis or before the diagnosis of malignant disease. The underlying causes of stroke in cancer patients are distinct from those in noncancer patients and are related to both cancer itself and the type of treatment. Cardio-embolism, large vessel atherosclerosis, and small vessel occlusion have all been identified as important causes of ischemic stroke, but nonbacterial thrombotic endocarditis has been documented only infrequently. We present a case of a 64-year-old female with recurrent ischemic stroke of unknown cause and involving different arterial territories, who was discovered to have metastatic pancreatic cancer. The initial workup with brain imaging revealed multiple acute/subacute ischemic strokes and a negative cardiac assessment. Accordingly, she underwent a whole-body positron emission tomography-computed tomography which revealed a hypermetabolic mass lesion in the pancreaticoduodenal area. Our case indicates that cancer-associated stroke should be seriously evaluated. It demonstrates the critical nature of contemplating hidden cancer in survivors of ischemic stroke and identifies factors that may necessitate further investigation as part of a comprehensive approach to ischemic stroke, especially embolic stroke of unknown sources.

Nonbacterial Thrombotic Endocarditis Associated with Acute Promyelocytic Leukemia: An Autopsy Case Report

Valve vegetation is one of the most fearful findings for physicians. The first diagnosis that comes to their mind is infective endocarditis (IE), but it can also be noninfective; nonbacterial thrombotic endocarditis (NBTE). NBTE can be even more challenging than IE for physicians because of the wide range of differential diagnoses such as malignancies, autoimmune disorders and human immunodeficiency virus. A 45-year-old woman presented at the emergency room with a sudden onset of dysarthria and right-sided hemiplegia. Laboratory data showed her blood counts and coagulation test were mostly normal and the magnetic resonance imaging detected a high-signal-intensity change in her left brain. An echocardiogram found a vegetation-like structure on her atrial valve. We highly suspected IE leading to cerebral embolism. The clot was successfully removed by our neurosurgeons and anticoagulation therapy was started concurrently. Her state of consciousness improved, but then she suffered a brain hemorrhage and died. The autopsy revealed that the cause of her vegetation was acute promyelocytic leukemia (APL). Based on these findings, it is important to remember that APL can be the cause of NBTE even if the blood count and coagulation tests are almost normal.

Mesothelioma with Nonbacterial Thrombotic Endocarditis: A Case Report

Non-bacterial thrombotic endocarditis is a rare condition characterized by noninfectious vegetation on cardiac valves which are often associated with malignancy. It often presents with features of embolism rather than cardiac failure. These are usually seen in autoimmune conditions, disseminated intravascular coagulation, malignancy of gut and lung but has also been reported in other malignancies as well. This entity is rare but one must have a clinical suspicion of the disease especially in a patient suffering from malignancy presenting with the embolic phenomenon. In this report, we are presenting a case of non-bacterial thrombotic endocarditis in an inpatient with pleural mesothelioma, a rare malignant neoplasm arising from pleura in a 35 years old mason, and a rare association as well.