SHM Converge Scientific Abstract ePoster Gallery-Risk-Benefit of Anticoagulation Initiation in a Patient With Left Ventricular Thrombus, Suspected Endocarditis, and Acute Thrombocytopenia

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This case describes a 59-year-old woman with fever, shock, encephalopathy, and an unwitnessed fall who was found to have MSSA bacteremia, acute kidney injury, and multifocal embolic-appearing cerebral infarcts. Her history included recurrent central line infections and prior intracranial hemorrhage from a pontine cavernous hemangioma, making anticoagulation decisions especially high risk.<br /><br />Initial evaluation showed a new left ventricular (LV) apical mass on transthoracic echocardiography, concerning for thrombus, vegetation, or tumor, along with new wall motion abnormalities. CT heart favored LV thrombus, and a nonocclusive superior vena cava (SVC) thrombus was also found after Hickman catheter removal. Brain MRI suggested septic or embolic infarcts, and concern remained for infective endocarditis and possible mycotic aneurysm. During hospitalization, the patient developed acute thrombocytopenia, with platelet nadir of 59, and an elevated INR, thought to reflect severe sepsis and later improved with vitamin K.<br /><br />Further workup included cardiac MRI, which showed transmural late gadolinium enhancement consistent with a recent myocardial infarction in the RCA/LCx territory. However, because the patient had no major coronary history, clinicians considered embolic or infection-related causes for the LV thrombus. Digital subtraction angiography showed no mycotic aneurysm, lowering concern for catastrophic intracranial bleeding with anticoagulation.<br /><br />After multidisciplinary discussion among medicine, neurology, infectious diseases, hematology, cardiac surgery, and neurosurgery, the team judged that the benefit of anticoagulation outweighed the bleeding risk once thrombocytopenia improved. The patient was started on heparin, blood cultures cleared on cefazolin, her mental status improved, and she was discharged to a skilled nursing facility on a DOAC. She died suddenly two days later.<br /><br />The key takeaway is that anticoagulation decisions in patients with bacteremia, cerebral emboli, LV thrombus, and thrombocytopenia require careful multidisciplinary risk-benefit assessment.

Asset Subtitle

A. Nikolai Von Krusenstiern

Meta Tag

Author List A. Nikolai Von Krusenstiern, Kaustav Shah

Category Clinical Vignettes

Concept Anticoagulation

Concept Left Ventricular Thrombus

Concept Infective Endocarditis

Concept Cerebral Infarction

Concept Intracranial Hemorrhage

Distinguished Non-Finalist

Presenter Organization Hospital of the University of Pennsylvania

Presenting Author A. Nikolai Von Krusenstiern

Track Adult

Keywords

MSSA bacteremia

left ventricular thrombus

cerebral embolic infarcts

septic emboli

thrombocytopenia

anticoagulation risk

infective endocarditis

acute kidney injury

superior vena cava thrombus

multidisciplinary management

Anticoagulation

Left Ventricular Thrombus

Infective Endocarditis

Cerebral Infarction

Intracranial Hemorrhage