A54-07 Libman-Sacks Endocarditis as the Sole Manifestation of Systemic Lupus Erythematosus Presenting With Ischemic Stroke

Abstract Libman-Sacks endocarditis (LSE) is a rare, noninfectious condition involving sterile vegetations on heart valves. It is primarily associated with systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APLS), with a prevalence of 0.9%. This case describes a young woman who initially presented with LSE as the first sign of SLE. A 31-year-old woman with a history of systemic hypertension presented with slurred speech. Examination revealed expressive aphasia, right hemianopsia, and left arm pronator drift. CT angiogram and cerebral perfusion imaging showed a left middle cerebral artery occlusion with a corresponding penumbra in the left parietal-occipital lobe. A transthoracic echocardiogram showed thickening of the aortic valve, and a transesophageal echocardiogram revealed a 0.9 × 0.61 cm vegetation on the right coronary cusp (Figure 1) and multiple eccentric jets, highlighting aortic regurgitation. Blood cultures were negative. An autoimmune workup revealed a positive antinuclear antibody at a titer of 1:160, elevated cardiolipin IgG at 58 and IgM at 16, and a positive double-stranded DNA antibody at 69. The patient underwent mechanical aortic valve replacement and was discharged on warfarin. Our case describes a relatively healthy female who presented to the emergency department with stroke-like symptoms, which led to the diagnosis of LSE and SLE. The patient showed no clinical signs of SLE; LSE was her initial presentation.While the exact mechanism is not fully understood, it is hypothesized that a hypercoagulable state causes endothelial injury, resulting in thrombotic and inflammatory deposits, most frequently affecting the mitral valve. Treatment often involves valve surgery due to the high risk of recurrent embolic events. Management with anticoagulants or anti-thrombotics remains poorly defined. In our case, the decision regarding definitive treatment was particularly challenging given the patient’s age and the risk for developing APLS, which would necessitate long-term anticoagulation. Additionally, repeated bioprosthetic valve replacements raised concerns about annular narrowing and patient-prosthesis mismatch, leading to the decision to implant a mechanical aortic valve. This case highlights the importance of maintaining a high index of suspicion for underlying systemic conditions in young patients presenting with stroke and highlights the need for further research into optimal medical management strategies. This abstract is funded by: None