SHM Converge Scientific Abstract ePoster Gallery-An Unexpected Aortic Vegetation in a Patient With Superior Mesenteric Artery Thrombosis

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A 63-year-old man with prior unprovoked DVT on rivaroxaban and a seizure disorder treated with phenytoin presented with acute abdominal pain, vomiting, and hematochezia. Imaging showed superior mesenteric artery occlusion causing acute mesenteric ischemia, requiring urgent small bowel resection. During surgery, transesophageal echocardiography unexpectedly revealed a large aortic vegetation with moderate aortic insufficiency.<br /><br />He was initially treated for possible infective endocarditis, but multiple blood cultures and tests for Coxiella, Brucella, and Bartonella were negative. Despite therapeutic heparin, he later developed a new right internal jugular DVT, raising concern for an underlying hypercoagulable disorder. Rheumatologic testing showed a high ANA titer, weakly positive dsDNA, positive lupus anticoagulant, borderline anticardiolipin and beta-2 glycoprotein IgM antibodies, and positive anti-histone antibodies.<br /><br />The overall picture was most consistent with antiphospholipid syndrome (APLS) complicated by marantic endocarditis, with drug-induced lupus likely related to phenytoin use. The combination of arterial thrombosis, recurrent venous thrombosis, and valvular vegetation supported this diagnosis. He ultimately underwent mechanical aortic valve replacement, and pathology showed a fibrotic calcified valve with attached thrombus rather than infection.<br /><br />He was discharged on warfarin with an INR goal of 2.5–3 and hydroxychloroquine. The case highlights that APLS can present atypically in older patients with mesenteric ischemia and may be missed if attributed only to atherosclerotic disease. It also emphasizes that warfarin is preferred over direct oral anticoagulants in APLS, especially after thrombotic events occur despite DOAC therapy.

Asset Subtitle

Junaid Khawaja

Meta Tag

Author List Aleesha Kainat, Anjana Chandrasekhara Pillai, Junaid Khawaja

Category Clinical Vignettes

Concept Antiphospholipid Antibody Syndrome

Concept Superior Mesenteric Artery Occlusion

Concept Marantic Endocarditis

Concept Warfarin

Concept Mesenteric Ischemia

Distinguished Non-Finalist

Presenter Organization Upmc

Presenting Author Junaid Khawaja

Track Adult

Keywords

antiphospholipid syndrome

marantic endocarditis

acute mesenteric ischemia

superior mesenteric artery occlusion

aortic vegetation

phenytoin

drug-induced lupus

lupus anticoagulant

warfarin

mechanical aortic valve replacement

Antiphospholipid Antibody Syndrome

Superior Mesenteric Artery Occlusion

Marantic Endocarditis

Warfarin

Mesenteric Ischemia