Case Presentation: The patient is a 59-year-old female with medical history notable for dysautonomia utilizing Hickman catheter for home fluids. The day before presentation, the patient was febrile and then was found down by a family member. Upon awakening, she had word-finding difficulties prompting emergency room presentation. On arrival to the ED she was in septic shock with blood cultures growing methicillin-sensitive Staphylococcus aureus. Her hemodynamics rapidly improved with resuscitation. Due to persistent altered mentation, she received a brain MRI which demonstrated multifocal punctate embolic-appearing acute infarcts. She was then admitted to the medicine service for management of suspected endocarditis. She underwent echocardiography which identified a 1.8 cm x 1.8 cm solid left ventricular (LV) apical mass. The Hickman catheter was removed for source control, and infectious diseases, neurology, and cardiac surgery were consulted. Many interdisciplinary discussions took place regarding anticoagulation in the setting of LV thrombus, thrombocytopenia of unclear etiology, and suspected endocarditis with potential septic emboli to the brain. Further imaging confirmed thrombus present in both the LV and SVC with normal ejection fraction. Digital subtraction angiography (DSA) performed by neurosurgery did not show any mycotic aneurysms. The patient subsequently cleared her blood cultures and was started on systemic anticoagulation after her thrombocytopenia improved. Surgery was not performed due to the risk of further embolism from manipulation of clot. The patient’s mental status slowly improved and after 13 days inpatient, the patient was transitioned to oral anticoagulation and discharged to rehabilitation facility. However, two days after discharge, patient suddenly passed away at the facility, where autopsy was declined by family.
Discussion: Hospital medicine physicians frequently face challenging anticoagulation decisions in patients with concurrent bleeding and thrombotic risk. This patient had acute LV thrombus with suspected embolic disease, however she also had concern for infective endocarditis with high risk of intracranial bleeding, and additionally developed acute thrombocytopenia. LV thrombi are commonly associated with acute myocardial infarction or severely reduced LVEF, neither of which were found in this patient. The patient had catheter associated thrombus, but this is a common complication and does not anatomically explain a concurrent LV thrombus. The patient may have presented with a sterile LV clot independent of the bacteremia, yet it was impossible to determine whether the clot was infected using numerous cardiac imaging modalities, and surgical intervention was deemed too high risk. Ultimately as DSA did not show mycotic aneurysm, the benefit of treating with anticoagulation outweighed the risk. The patient did ultimately pass after discharge from the hospital. It is unknown whether the cause of death was a complication of the LV thrombus itself or the anticoagulation, as both are possible in this patient.
Conclusions: This case contained several challenging management decisions surrounding anticoagulation in a patient with suspected endocarditis, new LV thrombus, acute thrombocytopenia and cerebral infarctions. Hospital medicine physicians should take efforts to lead multi-disciplinary discussions with infectious diseases, neurology, and cardiac and neurological surgery for these patients.