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Case of massive thromboembolism in a patient with necrotic vasculitis and inherited thrombophilia

Session Clinical Case Corner 4 - The great fire: inflammation of the heart and beyond

Speaker Elena Kosmacheva

Event : Heart Failure 2018

  • Topic : valvular, myocardial, pericardial, pulmonary, congenital heart disease
  • Sub-topic : Pulmonary Embolism
  • Session type : Clinical Case Posters

Authors : S Martirosyan (Krasnodar,RU), H Kosmachova (Krasnodar,RU), T Matushina (Krasnodar,RU)

S Martirosyan1 , H Kosmachova1 , T Matushina1 , 1Cuban Regional Clinical Hospital No 1 - Krasnodar - Russian Federation ,


Introduction: a 43-year-old women with preliminary diagnosis of right-heart infective endocarditis was delivered to our clinic to resolve the issue of surgery.
Presenting condition: pale skin with multiple rounded wounds in the scarring stage on the legs, progressive dyspnea with wet wheezes, SpO2 82-84%, arterial BP 100/80 mmHg.
Anamnesis: patient with no history of heart or vascular diseases. Rounded bullous rashes on legs with hyperemia and edema appeared 2 months earlier. Progressive dyspnea appeared  2 weeks ago. In regional hospital was suspected  right-heart infective endocarditis and the patient was sent to our clinic for surgery
Gynecological anamnesis: pregnancy - 9 miscarriage - 6

Identification of the problem: D-Dimer 3406 (N=243) NTproBNP - 7318 (N=110)
On ECG: sinus tachycardia HR˜140 Esco: MV - mid reg TV - med reg LA 22 mm LV 33 mm RA 50x55 mm RV 43 mm EF 38% Systolic Pulmonary artery pressure >100 mmHg NO EVIDENCE OF ENDOCARDITIS
Contrast-enhanced computed tomography of the chest: massive pulmonary embolism
Ultrasound of lower limbs: bilateral thrombosis of superficial femoral veins
Anticoagulation (enoxaparin 1 mg/kg each 12 h -> rivaroxaban 15 mg each 12 h) therapy, CPAP-BIPAP ventilation has been started. The patient's condition was stabilized in 2 weeks .

Questions and problems:
1. Was the diagnosis of right-heart infective endocarditis competent? Did this patient need the surgery? There were no any reasons for acquiring an infectious process on the tricuspid valve, so no need for surgery
2. What is the cause of massive thromboembolic events?
Considering gynecological anamnesis, in order to find the answer to this question, we conducted a genetic test for susceptibility to thrombophilia. The mutation in folate metabolism was found. So we added to the treatment folic acid.
3. What were the causes and nature of skin rashes?
We performed a biopsy of the skin flap with histological examination. The cutaneous form of necrotic leg ulcerative vasculitis was revealed.
This patient was discharged in a satisfactory condition with positive clinical dynamics.

Conclusions: the correct interpretation of heart failure symptoms and searching for etiological and pathogenic triggers of cardiac decompensation is the only way to successful treatment.

BP, mmHg HR, bpm SatQ2,% D-Dimer, ng/ml NTproBNP, pg/ml HB, g/l WBC
D1 100/80 140 82 3406 7318 92 10,6
D22 110/70 100 96 456 597 107 7,8
D1 - admission date, D29 - discharge date

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