Libman-Sacks endocarditis (LSE) is a form of nonbacterial thrombotic endocarditis (NBTE) observed in patients with malignancies, systemic lupus erythematosus (SLE), and antiphospholipid syndrome (APS), resulting from endothelial injury in a hypercoagulable state. The mitral and aortic valves are most commonly affected. Complications can include valvular injury, heart failure (HF), and widespread embolic events. We present a rare case of embolic stroke caused by NBTE in a 51-year-old man with no significant medical history. The patient presented to the emergency department with the sudden onset of slurred speech, numbness, and weakness in his right hand. Physical examination revealed Janeway lesions, splinter hemorrhages, and widespread livedo reticularis. Laboratory tests showed elevated anticardiolipin antibody (aCL-IgM), increased BNP and high-sensitivity troponin, thrombocytopenia (68,000/μL), and elevated homocysteine. Repeated blood cultures were negative. Computed tomography (CT) of the brain revealed chronic right posterior temporal, occipital, and left occipital infarctions. Magnetic resonance imaging (MRI) of the brain demonstrated numerous small foci of early subacute ischemia in both cerebral hemispheres and the left cerebellar hemisphere. A transthoracic echocardiogram (TTE) identified a 0.93 x 0.51 cm mobile echodensity near the right coronary cusp. Transesophageal echocardiography (TEE) confirmed verrucous and nodular vegetations with heterogeneous echodensity at the commissural border of both aortic valve leaflets, severe aortic regurgitation (AR), and reduced left ventricular ejection fraction (LVEF = 45–50%). The patient was diagnosed with an embolic stroke caused by LSE in the context of underlying APS. He was treated with low molecular weight heparin (LMWH), vancomycin, and piperacillintazobactam (Zosyn). Subsequently, he underwent mechanical aortic valve replacement followed by warfarin therapy (target INR 3-4). Intraoperative findings confirmed thickening and numerous tiny nodular vegetations on the aortic valve. This case highlights the importance of early diagnosis of embolic stroke caused by NBTE in young patients without significant medical history. Prompt and appropriate treatment, including antibiotics, anticoagulants, and surgery, is crucial to prevent serious complications.
Lam et al. (Fri,) studied this question.