Introduction: Albeit a frequent complication in cancer patients, stroke has rarely been reported as an initial manifestation of an occult malignancy. We report a patient presenting with multifocal cerebral infarction who was later found to have an adenocarcinoma of lung complicated with Non Bacterial Thrombotic Endocarditis (NBTE) and Disseminated Intravascular Coagulation (DIC). Case report: A 70–year–old female smoker with history of chronic obstructive pulmonary disease presented with one day history of acute onset dizziness and several weeks of generalized fatigue. Neurological examination showed dysmetria with positive cerebellar signs and ataxic gait. Laboratory tests revealed elevated prothrombin time(14.1secs) and INR(1.31), MRI of the brain revealed multifocal acute infarcts involving left cerebellar hemisphere, left frontal lobe, right parietal lobe and right frontal lobe along with multiple areas of hemorrhagic infarct. Due to her multifocal cerebral involvement, a transesophageal echocardiogram was done which showed a 3mm vegetation attached to the right coronary cusp of the aortic valve. It was thought to be secondary to NBTE as infectious origin was excluded given lack of fever, normal white cell count and multiple negative blood cultures. Further work up revealed increased prothrombin time(18.7sec), elevated D dimer(21,640), increased fibrin degradation products(>20), very low fibrinogen(63 mg/dL) and low platelets(107,000 per hpf), consistent with DIC. Due to the co–existence of NBTE, DIC and multifocal cerebral infarct, further work up for an occult malignancy was initiated. CT scan of chest showed a spiculated nodule in the right middle lobe of the lung along with multiple enlarged lymph nodes in the mediastinum and axilla. Biopsy of axillary lymph nodes revealed a poorly differentiated adenocarcinoma of pulmonary primary. Patient was treated with vinorelbine and prednisone with which she has recovered well and has not had any recurrence.
Cancer coagulopathy was first reported by Trousseau in 1865. Today it is widely recognized to include migratory thrombophlebitis, deep vein thrombosis, arterial thrombosis, microangiopathy, NBTE and DIC. NBTE and DIC are common etiologies for multifocal cerebral infarcts in cancer patients and offer the best explanation for stroke in our patient. The most common malignancies causing coagulopathy are pancreatic, ovarian, prostate cancers, and mucin producing adenocarcinoma of the lung, which also are the most prevalent cancers in the general population. Optimal treatment should be directed against the underlying neoplasm in these patients.
This case report signifies the importance of investigation for an occult malignancy in a patient with multifocal cerebrovascular event especially when associated with NBTE or DIC.