PO070 | INFECTIVE ENDOCARDITIS AND ISCHEMIC CEREBRAL EVENTS IN A PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS AND TRIPLE ANTIPHOSPHOLIPID POSITIVITY: THE ROLE OF ANTICOAGULATION IN PRIMARY PREVENTION
Abstract
Background. The management of thrombotic risk in patients with triple positivity for antiphospholipid antibodies in the absence of clinical events remains controversial, particularly in the setting of systemic lupus erythematosus (SLE). The role of anticoagulation for primary prevention is not clearly established, especially in complex clinical scenarios such as infective endocarditis. Case Report. A 29-year-old woman (52 kg) with a history of SLE and persistently high-titer triple-positive antiphospholipid antibodies, with no prior thrombotic events, was receiving mycophenolate mofetil and low-dose aspirin. She was admitted for infective endocarditis due to methicillin-sensitive Staphylococcus aureus involving the aortic valve. The condition was complicated by multiple ischemic cerebral events affecting the temporo-parietal and right fronto-parietal regions, resulting in right-sided facio-brachio-crural hemiplegia, without evidence of hemorrhagic transformation. Concurrently, septic dissemination to the liver, spleen, and osteo-articular system was documented. Lower limb Doppler ultrasound was negative for thrombosis. The patient underwent mechanical thrombectomy of the right middle cerebral artery, followed by surgical aortic valve replacement with a mechanical prosthesis. She was treated with cefazolin for six weeks. During the perioperative period, immunosuppressive therapy was discontinued, and anticoagulation was initiated with low-molecular-weight heparin, later transitioned to warfarin. Laboratory findings showed mild neutrophilic leukocytosis, normochromic anemia, and persistent high-titer antiphospholipid antibody positivity. The clinical picture was consistent with septic embolization secondary to infective endocarditis rather than a primary thrombotic event related to antiphospholipid syndrome. Although triple positivity represents a high thrombotic risk factor, in the absence of prior thrombotic events it does not constitute a well-established indication for anticoagulation according to current EULAR recommendations. Moreover, anticoagulation does not prevent septic embolic complications and may increase the risk of bleeding during the acute phase. While a concomitant thrombotic component could not be entirely excluded, the predominant mechanism underlying the clinical presentation appears to be infectious and embolic. Conclusions. This case highlights the need for individualized assessment of both thrombotic and hemorrhagic risk in complex clinical scenarios. It also raises a critical question: could primary thromboprophylaxis with anticoagulants have prevented such severe and disabling events in this patient?
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BibTeX
@article{marrazzo2026po070,
title = {{PO070 | INFECTIVE ENDOCARDITIS AND ISCHEMIC CEREBRAL EVENTS IN A PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS AND TRIPLE ANTIPHOSPHOLIPID POSITIVITY: THE ROLE OF ANTICOAGULATION IN PRIMARY PREVENTION}},
author = {Tommaso Marrazzo},
journal = {Bleeding, Thrombosis and Vascular Biology},
year = {2026},
month = oct,
url = {https://www.btvb.org/btvb/article/view/886},
note = {CC BY-NC},
}
RIS
TY - JOUR
TI - PO070 | INFECTIVE ENDOCARDITIS AND ISCHEMIC CEREBRAL EVENTS IN A PATIENT WITH SYSTEMIC LUPUS ERYTHEMATOSUS AND TRIPLE ANTIPHOSPHOLIPID POSITIVITY: THE ROLE OF ANTICOAGULATION IN PRIMARY PREVENTION
AU - Tommaso Marrazzo
PY - 2026
DA - 2026/10/26
JO - Bleeding, Thrombosis and Vascular Biology
UR - https://www.btvb.org/btvb/article/view/886
AB - Background. The management of thrombotic risk in patients with triple positivity for antiphospholipid antibodies in the absence of clinical events remains controversial, particularly in the setting of systemic lupus erythematosus (SLE). The role of anticoagulation for primary prevention is not clearly established, especially in complex clinical scenarios such as infective endocarditis. Case Report. A 29-year-old woman (52 kg) with a history of SLE and persistently high-titer triple-positive antiphospholipid antibodies, with no prior thrombotic events, was receiving mycophenolate mofetil and low-dose aspirin. She was admitted for infective endocarditis due to methicillin-sensitive Staphylococcus aureus involving the aortic valve. The condition was complicated by multiple ischemic cerebral events affecting the temporo-parietal and right fronto-parietal regions, resulting in right-sided facio-brachio-crural hemiplegia, without evidence of hemorrhagic transformation. Concurrently, septic dissemination to the liver, spleen, and osteo-articular system was documented. Lower limb Doppler ultrasound was negative for thrombosis. The patient underwent mechanical thrombectomy of the right middle cerebral artery, followed by surgical aortic valve replacement with a mechanical prosthesis. She was treated with cefazolin for six weeks. During the perioperative period, immunosuppressive therapy was discontinued, and anticoagulation was initiated with low-molecular-weight heparin, later transitioned to warfarin. Laboratory findings showed mild neutrophilic leukocytosis, normochromic anemia, and persistent high-titer antiphospholipid antibody positivity. The clinical picture was consistent with septic embolization secondary to infective endocarditis rather than a primary thrombotic event related to antiphospholipid syndrome. Although triple positivity represents a high thrombotic risk factor, in the absence of prior thrombotic events it does not constitute a well-established indication for anticoagulation according to current EULAR recommendations. Moreover, anticoagulation does not prevent septic embolic complications and may increase the risk of bleeding during the acute phase. While a concomitant thrombotic component could not be entirely excluded, the predominant mechanism underlying the clinical presentation appears to be infectious and embolic. Conclusions. This case highlights the need for individualized assessment of both thrombotic and hemorrhagic risk in complex clinical scenarios. It also raises a critical question: could primary thromboprophylaxis with anticoagulants have prevented such severe and disabling events in this patient?
SN - 2785-5309
ER -