1. Mahmoud Sabbah, MSc Cardiology department Suez canal University
Case Presentation
Mahmoud Sabbah, MSc
Cardiology department
Suez canal University

2. History & Clinical Course
A 38 y/o male patient recently diagnosed SLE 3 months back on medical TTT (corticosteroid ,cyclophosphamid,……. )
admitted to renal department because of deteriorating course with fever ,overwhelming Sepsis and multiple abscesses allover the body including liver.

3. During the treatment course, patient lost his LT eye vision 3 month back then his RT one because of uveitis and retinal detachment.

4. A cardiological consultation was requested because of having recurrent attacks of dyspnea at rest with palpitation and diffuse plueritic stitching chest pain,
N.B Patient has past history of pericarditis and pericardial effusion at the time of initial therapy.

5. Physical Examination
Patient looks ill, puffy face, cachectic, malnourished and has diffuse body tenderness with multiple abscesses all over the body.
But lying flat with no signs of CHF.
B.P:170/105 mmHg, pulse 110 bpm &irregular. JVP: raised.
All peripheral pulsation were intact and no lower limb edema
On auscultation, normal S1, S2 with no additional sounds. and clear both lung bases with no signs of LVF

6. Investigations ESR : 1st hour~80 mm and 2nd hour > 100 mm
ANCA(Immunofluorescence) → positive,
ANA →positive. Complement C3& C4 were normal CRP~88.0 mg/L N (up to 10)
Anti- Cardiolipin IgG & IgM→ highly positive.
Prothrombin Time(PT) and activated partial thromboplastin Time(aPTT) were normal
Renal Biopsy: Proliferative Exudative GN with focal mesangiocapilary Changes.

7. ECG: sinus tachycardia with multiple premature atrial contractions and prolonged PR interval.
Previous ECHO(3 month back): Conc. LVH with moderate pericardial effusion.No tamponade or masses
Based on the previous presentation and data ECHo was requested:

18. Echo Data LV: Concentric LVH with fair systolic function;
No resting RWMA
Mild Pericardial effusion
At least 3 different sizes ,mobile ,pedicled echogenic masses seen at the LV cavity ( Adhered to contractile myocardium)
Finger-like mass seen attached to the ventricular side of the AV leaflet.
RV: normal size & function. 2 mobile, pedicled echogenic masses also seen in its cavity

19. Multi-Chamber Intracardiac masses (Intracavitary & valvular)

20. Differential Diagnosis
APICAL MASSES:
- Thrombus (akinetic segments)
- Leofler’s syndrome.
- Endomyocardial fibrosis (seen in tropics)
- Antiphospholipid Ab. syndrome.
- Behçet disease (BD)
Multiple intracardiac tumors
Primary Cardiac Tumors:
Secondary Cardiac Tumors
??Vegetations (attached to valve leaflets and
move independently to the valvular movement
NL Wall Motion

21. Investigations Are there any valuable diagnostic tool in this case??
- TEE.
- Contrast Echo.
-?? Multislice CT.
-?? MRI.

22. Multiple Intarcardiac Thrombosis With high likelihood of IE vegetation
???Probable Diagnosis
Multiple Intarcardiac Thrombosis
With high likelihood of IE vegetation

23. Decision after discussion
Prompt initiation of anticoagulation &
antibiotics (for IE) after consultation of
ophthalmologist and nephrologist for fear of
any contraindications.

24. Continuation of the Sad Story……
After 7 doses of IV UFH (5,000 IU/dose) and 10 mg warfarin.
The patient get disturbed LOC. But heamodynamically stable and no bleeding per any orifices.
Urgent Neurological consultation and CT brain was done revealed
massive intracerebral heamrahage.
Urgent ICU admission &stopping of anticoagulant
But unfortunately it was the last place in his life as he passed away

25. Take Home Message
Follow up ECHO assessment of SLE PTs is of great value as initial look.
SLE was associated with thrombus formation especially with positive test results for Anti- Cardiolipin IgG & IgM
Certain Hematological disease carries a great risk for developing Cardiac thrombosis during disease course, hence need frequent assessment .
BP should be freqently&effectively monitored before and during anticoagulation use.

26. Questions for Discussion ……
Use of OAC,Is it a good decision?
Are there any role for thrombolytics???
Is it a realistic scenario to develop hemorrhagic stroke??

27. Thank You
Thank You