Caseous Calcification of the Mitral Annulus Confounded by Antiphospholipid Antibodies

BACKGROUND: Multifocal stroke with positive antiphospholipid antibodies (aPLs) can obscure alternative embolic etiologies. We present a case of embolizing caseous calcification of the mitral annulus (CCMA). CASE SUMMARY: A 77-year-old woman presented with acute gait instability and mild left-sided weakness. Laboratory evaluation revealed positive aPLs. Neuroimaging demonstrated multifocal acute infarcts with calcified cerebral emboli. Transesophageal echo revealed extensive mitral annular calcification with an attached mobile echodense mass. Final surgical pathology confirmed a sterile CCMA. DISCUSSION: Concurrent positive aPL testing complicated the evaluation of multifocal embolic strokes. Multimodality imaging led to the appropriate diagnosis and management of CCMA. TAKE-HOME MESSAGES: Positive aPL testing should not preclude continued evaluation for alternative structural embolic sources. CCMA with extensive embolization warrants surgical evaluation because anticoagulation alone does not eliminate the embolic risk.