ODP451 A Case of Papillary Thyroid Cancer Presenting with Marantic Endocarditis and Recurrent Stroke

Marantic endocarditis or non-bacterial thrombotic endocarditis (NBTE) is characterized by the presence of vegetations on cardiac valves, which consist of fibrin and platelet aggregates and are devoid of inflammation or bacteria. The hypercoagulable state associated with malignancy is well known to be associated with NBTE. Here we report a rare case of Papillary Thyroid Cancer presenting with Marantic Endocarditis and Recurrent Stroke. A 52-year-old lady, with medical background of hypertension, presented to the Emergency Department with history of sudden onset of difficulty in speaking for 3 days. On examination she had slurred speech and tongue deviation to the right side. Neurological examination was otherwise normal. Imaging revealed left frontal, right frontal and left cerebellar infarcts. Transthoracic Echocardiogram showed a large, highly mobile vegetation 18 mm in size, attached to the posterior mitral valve leaflet as well as severe Mitral Regurgitation. She was diagnosed as a case of Cardioembolic ischemic stroke due to endocarditis. She completed a course of empiric antibiotic therapy. However, her blood cultures and fungal culture revealed no growth. After 5 years, she again presented to the hospital with acute stroke. Trans esophageal Echocardiography now revealed multiple filamentous vegetations on the atrial surface of mitral valve, largest measuring 20 mm×4 mm. Her inflammatory markers were negative and 3 sets of blood cultures were again negative. A question was raised, as to whether the filamentous masses represent prolapsing ruptured chordae tendinae rather than vegetations. FDG PET-CT scan was thus performed and revealed: Left thyroid lobe focal uptake seen with an FDG-avid left parajugular lymph node. Ultrasound neck was then performed, which showed bilateral thyroid nodules with high suspicion ultrasound pattern per American Thyroid Association: ill-defined nodule seen in the lower pole measuring 8×8×7 mm with multiple foci of macrocalcification. Thyroid function tests were normal. Ultrasound guided thyroid fine needle aspiration (FNA) biopsy of the left thyroid nodule was performed. The cytology report was consistent with papillary thyroid carcinoma. She is planned for total thyroidectomy, after undergoing mitral valve replacement surgery. This case illustrates one of the paraneoplastic syndromes associated with thyroid cancer. A hypercoagulable state has been observed in several types of thyroid cancer, although the pathogenesis has not been well studied. The etiology of cancer-associated coagulopathy is complex, related to an imbalance in the hemostatic system and abnormal levels of coagulation factors. Further studies on the occurrence of thrombosis in different types of thyroid cancer would help to inform clinical practice in the management of thyroid cancer, including the need for anticoagulation in certain situations. Presentation: No date and time listed