Nonbacterial Thrombotic Endocarditis (Libman-Sacks) as a Complication of Metastatic Pancreatic Cancer: A Case Report of Diagnostic and Therapeutic Challenges

Libman-Sacks endocarditis (LSE), or nonbacterial thrombotic endocarditis (NBTE), is a rare condition most commonly associated with systemic lupus erythematosus (SLE), but it may also occur in patients with malignancies. NBTE is an underrecognized cause of cancer-associated embolic strokes of undetermined source. We report the case of a 68-year-old female with metastatic pancreatic adenocarcinoma who presented with acute visual disturbances and headaches. Neuroimaging revealed multiple embolic infarcts in different vascular territories. Transesophageal echocardiography (TEE) identified a mass on the posterior mitral valve, consistent with sterile thrombus formation. Laboratory and imaging studies confirmed advanced pancreatic cancer, creating a hypercoagulable state likely responsible for NBTE. The patient was managed with anticoagulation using low-molecular-weight heparin and palliative chemotherapy targeting the underlying malignancy. Despite these interventions, her clinical course progressed with recurrent embolic events and systemic decline, ultimately necessitating hospice care. This case highlights the diagnostic challenges of NBTE in malignancy, emphasizing the need to consider this condition in patients with multiple embolic strokes of varying ages. Early recognition through neuroimaging and echocardiography is essential for timely anticoagulation and multidisciplinary management. Clinicians should maintain a high index of suspicion for NBTE in patients with prothrombotic cancers, such as pancreatic adenocarcinoma, as prompt diagnosis can guide appropriate therapy and optimize quality of life.