Non-bacterial thrombotic endocarditis leading to the diagnosis of pancreatic adenocarcinoma

Non-bacterial thrombotic endocarditis (NBTE) is a rare, non-infective endocarditis affecting cardiac structures, often associated with underlying conditions and is frequently overlooked or misdiagnosed.We present the case of a man in his 50s who initially presented with symptoms concerning for myocardial ischaemia, and laboratory and ECG findings raised suspicion for a subacute non-ST-elevation myocardial infarction. Coronary angiography showed coronary sclerosis without significant stenoses and a dilated left ventricle with reduced systolic function. Transthoracic echocardiography revealed vegetations on a bicuspid aortic valve, while blood cultures were negative. Subsequent imaging identified a mass in the pancreatic head with liver metastases, confirmed as an adenocarcinoma by biopsy. The diagnosis of NBTE was established based on the presence of a malignancy, persistent negative blood cultures and the absence of laboratory signs of infection. Antibiotics were discontinued, and heparin therapy was initiated, emphasising NBTE as a paraneoplastic syndrome with a prothrombotic state without criteria for infectious endocarditis.