A 69-year-old male was admitted to a hospital in June 2016 because of right arm asthenia and dysarthria and was diagnosed as having cerebral infarction in the left middle cerebral artery area along with deep vein thrombosis. ECG demonstrated normal sinus rhythm and echocardiography revealed no intra-cardiac thrombus or vegetation. The patient was discharged from the hospital following administration of apixaban.\nIn August 2016, the patient was readmitted to the hospital because of recurrent right arm asthenia and dysarthria. MRI revealed multiple cerebral infarctions in not only the bilateral cerebral hemispheres but also the cerebellum. Trousseau’s syndrome was suspected at this time. Apixaban administration was stopped and an intravenous drip of heparin was started. Echocardiography revealed mild mitral regurgitation with vegetation on the mitral valve. Although the laboratory data suggested no evidence of infection, ceftriaxone and gentamicin were added as a precaution against infective endocarditis. The patient was then referred to our hospital for surgery.\nA CT scan revealed a left renal infarction and multiple swollen lymph nodes around both the abdominal aorta and stomach with antral hypertrophy, suggesting an advanced gastric cancer or lymphoma. As the vegetation showed no change despite the heparin and antibiotics therapy, cardiac surgery was performed on day 5 after referral. Extracorporeal circulation was instituted employing aortic and bicaval cannulation. After aortic cross-clamping, the mitral valve was exposed via a left atriotomy. Both mitral leaflets had vegetation on the surface, and major vegetation 15 mm in width was evident on the anterior leaflet (Fig. ). These were resected in their entirety and replaced with a 25-mm Epic bioprosthesis (Abbott). Continuous intravenous heparin administration was resumed on the following day, aiming for an activated partial thromboplastin time of between 40 and 50 s. Histologic analysis revealed that the vegetations were thrombi covered with vascular endothelium and that the mitral leaflet tissue was not damaged (Fig. ). On the basis of these findings, the patient was diagnosed as having NBTE.\nAn endoscopic stomach biopsy was performed on the seventh postoperative day, and histologic analysis revealed non-solid poorly differentiated adenocarcinoma with components of signet-ring cell carcinoma and moderately differentiated tubular adenocarcinoma. The patient was definitively diagnosed as having Trousseau’s syndrome and, subsequently, transferred to the department of surgery. A Billroth I distal gastrectomy was performed, and a continuous intravenous heparin drip was employed during the operation. Histologic analysis revealed poorly differentiated adenocarcinoma with a component of moderately differentiated tubular adenocarcinoma and metastatic tumor cells in the dissected lymph nodes (T4aN3bM0; stage IIIb). Further histologic analysis using alcian blue staining confirmed the presence of mucin in the tumor.\nSubcutaneous heparin injection was introduced on day 8 after the gastric surgery, and the patient was discharged from our hospital in October after acquisition of the self-injection technique. During this long hospitalization, no thromboembolic events were observed. Chemotherapy was started in November. The patient has survived for 18 months after the diagnosis of Trousseau’s syndrome without any recurrence of thromboembolism.
A 73-year-old Japanese woman experienced light-headedness and dementia of unknown cause for 6 months. She had had diabetes for 20 years and had a history of surgical excision of breast cancer and laparoscopic cholecystectomy 10 and 20 years before, respectively. Her neurological disturbance had advanced, and she sought treatment at Kansai Medical University Kori Hospital.\nAt the first medical examination, no abnormalities were detected by brain computed tomography (CT) scan. However, 1 month after the consultation, the patient experienced general hypotonia with progressive dementia and was hospitalized. At the time of admission, her blood coagulation tests were as follows (normal range in parentheses): platelets 6.8 × 104/μl (14–34 × 104/μl), fibrinogen 74.0 mg/dl (180–355 mg/dl), D-dimer 101.6 μg/ml (0–0.9 μg/ml), prothrombin time 81.2% (75–130%) and activated partial thromboplastin time 27.9 s (23–35 s). Her serum albumin had decreased to 1.8 g/dl (3.8–5.0 mg/dl), and γ-GTP had increased to 172 U/l (8–45 U/l). The serum CA19-9 level was 376,100 U/ml (<37 U/ml), and the CA15-3 level was 124 U/ml (<27 U/ml), both of which were significantly increased. Upper abdominal CT scan revealed a large ill-defined mass in the periphery of the right liver lobe and multiple ischemic lesions in the spleen. Because of her poor condition, further examination of the liver mass was impossible. Cerebral magnetic resonance imaging showed multi-regional hypointense areas in the hemisphere of her right cortex, which were compatible with acute cerebral infarction. Cardiac ultrasound showed abnormal movements in the mitral and aortic valves.\nDespite continuous anticoagulant therapy, her consciousness deteriorated and she died 3 months after the hospitalization due to multiple organ failure. The postmortem examination was performed 8 h after her death. The main object of the autopsy was to elucidate the pathological cause of the cerebral infarction.