CRA14 A TWO FACE MASQUERADER IN THE DOWN UNDER

Justin Yu Kuan Tan, Oliver Bennett, Kwun M Fong
1. Thoracic Medicine Department, The Prince Charles Hospital, Brisbane, Australia.

Introduction:

Marantic endocarditis which is also known as non-bacteria thrombotic endocarditis is often associated with adenocarcinoma.  It is a deposition of thrombus and fibrinous material in the heart valve and most commonly on the mitral valve. 

Case report:

We herein report the case of a 62-year-old painter who presented with acute shortness of breath, fever and weight loss. History of current polysubstance misuse including IV heroin and tobacco smoking, and a single pulmonary nodule (12 x 10 mm) in the lingula detected incidentally on a CT pulmonary angiogram, investigation; FBC; Haemoglobin 15.0 g/dL, WBC 9.9, platelet 270, Renal profile; urea 6.9 µmol/l, creatinine 126 mmol/l, LDH 175 U/L, CRP <0.5 mg/L. CT chest showed marked increase in size of the pulmonary nodule (63 x 58 x 75 mm) with innumerable small pulmonary nodules. Physical examination: Febrile, cachexia, splinter haemorrhages, and a systolic murmur loudest at the left sternal edge. An urgent transthoracic echocardiogram showed a mobile mass attached to the distal anterior leaflet of the mitral valve. With these findings he was treated for drug use-associated infective endocarditis with septic pulmonary emboli using ceftriaxone. After 72 hours, he remained febrile, prior blood cultures remained negative and a transoesophageal echocardiogram did not identify the vegetation previously detected by transthoracic echocardiogram. In view of failure to improve with broad-spectrum antibiotics, an ultrasound-guided fine needle aspiration of an enlarged left supraclavicular lymph node was performed. HPE revealed a metastatic adenocarcinoma with scattered TTF-1 positivity, consistent with primary lung origin.  Using historical imaging, we calculated the volume doubling time to be 8 days. Cross-sectional staging scans revealed extensive metastatic disease.  His case was discussed in the pulmonary malignancy multidisciplinary conference, with a consensus for best supportive care given the patient’s very poor performance status, frailty and comorbidities. 

Conclusion:

This case illustrates a very rapidly growing poor prognosis lung cancer which presented with features of infective endocarditis.