Non-bacterial Thrombotic Endocarditis Presenting as a Mass in the Right Atrium Diagnosed by Open Chest Surgery

Figures

• 

  Figure 1.. Cranial magnetic resonance imaging (diffusion weighted image) at the previous hospital. An embolus in the left middle cerebral artery was observed.

• 

  Figure 2.. (a) Findings of a 12-lead electrocardiogram at the time of admission. A sinus rhythm of 75 bpm without specific changes in the ST-T wave was shown. (b) Chest X-ray findings at the time of admission. Expansion of the cardiothoracic ratio of 62% and pulmonary congestion were shown.

• 

  Figure 3.. Transthoracic echocardiography findings at the time of admission. Aortic valve: Thickening of the non-coronary cusp (a) and moderate regurgitation with displacement in the direction of the inferior wall (b). Mitral valve: Thickening of both leaflets and several vegetations (maximum of 9 mm) with mobility on the valve (c) as well as severe regurgitation were observed (d). Right atrium: A multilocular mass lesion measuring 52×20 mm is observed (e, f).

• 

  Figure 4.. Transesophageal echocardiography findings on hospital day 12. Aortic valve: Thickening of all three cusps, especially the non-coronary cusp, is observed (a). Mitral valve: Thickening of the anterior and posterior leaflets is observed (b). RA: A movable and multilocular mass lesion of 34×13 mm with irregular edges and an uneven interior near the inferior vena cava and on the free wall side is observed (c).

• 

  Figure 5.. Contrast enhanced computed tomography scan in the axial view (a) and coronal view (b) at the time of admission. Peripheral pulmonary embolisms on both sides were observed.

• 

  Figure 6.. Ophthalmoscopy on day 2. Roth spots were detected in the right eye.

• 

  Figure 7.. (a) Surgical specimen of the mass in the RA. The size was 30×20 mm. It resembled an organized thrombus and had hard collusion with the atrial wall. (b) Surgical specimen of the aortic valve. All three cusps showed adhesion of the structure on the left ventricular side. (c) Surgical specimen of the mitral valve. A structure resembling the aortic valve was attached to both the anterior and posterior leaflets.

• 

  Figure 8.. The pathological examination of the specimens removed from the aortic and mitral valves. Wall destruction and fibrin deposition without obvious bacteria masses were detected by Hematoxylin and Eosin staining.

• 

  Figure 9.. Abdominal computed tomography findings. Multiple liver metastases of unknown origin were found.