Nonbacterial Thrombotic Endocarditis in a 78-Year-Old Female With Recurrent Acute Ischemic Stroke: A Case Report

Nonbacterial thrombotic endocarditis (NBTE) is a rare but serious complication, particularly in patients with malignancies like acute myeloid leukemia (AML), where a hypercoagulable state increases the risk of embolic events. This case report describes a rare and complex presentation of marantic endocarditis in a 78-year-old female with relapsed AML. The uniqueness of this case lies in the intersection of a hypercoagulable state induced by AML and the resultant NBTE, leading to recurrent embolic strokes, despite oral anticoagulation. This case contributes to the scientific literature by highlighting the diagnostic and therapeutic challenges in managing NBTE in patients with hematologic malignancies. The patient had multiple ED visits, initially with concerns of persistent back spasms, and was diagnosed with venous thromboembolism and started on apixaban.​ She then returned to our ED with visual disturbances and headaches. Significant clinical findings included right hemianopsia and circulating blasts on laboratory tests, indicative of AML relapse. Imaging studies revealed multiple small acute cerebral infarctions and evidence of thrombus affecting the mitral and aortic valves. The patient was diagnosed with NBTE and treated with systemic anticoagulation using warfarin, bridged with enoxaparin sodium. She remained stable during hospitalization and was discharged with follow-up care coordinated among her oncology, neurology, and cardiology teams. NBTE is an important consideration in a differential diagnosis in patients with cancer causing a hypercoagulable state such as AML, particularly in patients who present with neurological symptoms. High index of suspicion and a multidisciplinary approach are essential for the timely diagnosis and management of NBTE to prevent further thromboembolic complications.