Recurrent embolic strokes due to antiphospholipid syndrome and non-bacterial thrombotic endocarditis in a patient with basal cell carcinoma.

BACKGROUND: Non-Bacterial Thrombotic Endocarditis (NBTE) is a common form of aseptic thrombotic endocarditis that primarily affects mitral valves and less frequently aortic valves. NBTE is caused by systemic inflammatory reactions. This condition induces valve thickening or attached sterile mobile vegetation. NBTE is mostly asymptomatic; however, major clinical manifestations result from systemic emboli rather than valve dysfunction. When significant damage occurs, valvular insufficiency or stenosis can appear and promote heart failure occasionally requiring valve replacement surgery. NBTE is associated with hypercoagulable states, systemic lupus erythematous (SLE), antiphospholipid syndrome, or malignancies. CASE PRESENTATION: We report successful biological aortic valve replacement surgery including cardiopulmonary bypass for a 78-year-old man with NBTE and voluminous vegetation on the aortic valve inducing moderate aortic insufficiency and acute heart failure. The histopathological analysis of the valve sample showed myxoid degeneration, fibrous remodeling, and partial necrosis without any bacteria, thus indicating marantic endocarditis. Initially, the patient presented to the emergency department with an acute stroke. He was already using Apixaban treatment for a history of atrial fibrillation and cardioembolic stroke. Because of the recurrence of stroke and appearance of aortic vegetation, the investigations were extended. The antiphospholipid antibodies were positive without any indication of bacterial endocarditis. The malignancy screening was positive for basal cell carcinoma (BCC). The surgery and postoperative course were uneventful, and the patient was discharged with vitamin K antagonists (VKA). To our knowledge, NBTE with such a volume is rare and its apparent association with BCC has not been previously reported. CONCLUSION: Outside of SLE and antiphospholipid syndrome, NBTE is a rare and underdiagnosed disease associated with thromboembolic events. Adequate anticoagulation is a cornerstone of its treatment. Anticoagulation management during perioperative care and valve surgery deserves specific attention and helps to protect the patient from embolic complications. In the case of stroke and thromboembolic events of unclear cause or suspected NBTE, echocardiography and thrombophilia assessments including an immunological workup are recommended.

Pediatric Trauma: Six Years of Experience in a Swiss Trauma Center.

OBJECTIVES: The purpose of this study was to provide an internationally comparable overview of pediatric trauma of the University Hospital of Lausanne to improve the care of children. METHODS: We analyzed the data from all injured children (<16 years of age) listed in our trauma registry from 2011 to 2016. These children were admitted to the resuscitation room after prehospital triage. Our data were analyzed using descriptive statistics. RESULTS: We included 327 children. Sixty-three percent were male, and the median age was 8 years. Severe trauma (Injury Severity Score (ISS), >15) occurred in 97 children. The principal mechanisms of injury were falls (45%), traffic accidents (29%), and burns (14%). The most frequently affected areas were the head and external body regions. Intensive care admissions amounted to 27%. Twenty percent of patients underwent immediate surgery (wound care, neurosurgery, and orthopedic surgery). The overall mortality rate was 5.5%, with a median ISS of 9. The mortality of severe trauma was 17.5%, with a median ISS of 22. Half of the children died within 6 hours. The main causes of death were falls from greater than 5 m and traffic accidents as pedestrians. CONCLUSIONS: The demographics and patterns of injury in the pediatric trauma population are similar to other European pediatric trauma centers, but the mortality and the severity of injuries can vary (United Kingdom, 3.7%, median ISS of 9; Denmark, 7.3%, median ISS of 9; and Germany, 13.4%, median ISS of 25). The elevated early mortality rate suggests that improvements in prehospital care and early resuscitation could decrease mortality.