Welcome back to another Clinical Image of the Month from the case files of the Brown EM Residency.

HPI/ROS

A 77 y.o. female with PMHx significant for liver cirrhosis, COPD on 2L O2, fibromyalgia, depression, and GERD who presents to the ED for evaluation of abdominal and RLE pain after a mechanical fall. Patient denies head trauma and LOC and is not on blood thinners. Patient does report moderate ETOH use. Her mobility is quite limited by both her fibromyalgia as well as her underlying dyspnea which has previously been attributed to her COPD. She reports having episodes of diaphoresis for at least one to two years, which occur on a daily basis. She denies any clear fevers. She additionally denies any clear exertional chest pain or other associated complaints.

Vital signs are stable. Patient had a right hip XR which revealed a displaced and mildly angulated femoral neck fracture with moderate override and no other acute osseous or articular abnormality. An incidental finding was seen on the CT abdomen and pelvis, partially shown below:

CT A/P

Abdomen

Lower chest: Cardiomegaly. Arteriosclerosis of the aorta and coronary arteries. There is left ventricular apical bulbous morphology suggesting old MI. A 21 x 11 mm thrombus is seen in the LV apex. Moderate bilateral pleural effusions with associated relaxation atelectasis. Large hiatal hernia.

Cardiology was consulted for the LV thrombus. In the Emergency Department, an echocardiogram which showed severely reduced LV function (EF25%), moderately reduced RV function and redemonstrated the LV apical thrombus. Additionally, a mobile mass on the aortic valve was noted.

Echocardiogram 2D Complete

• Left ventricle is mildly dilated and global systolic function is severely reduced

• There is a fixed non-mobile 10mm X 15mm thrombus at the LV apex

• Right ventricle is dilated with moderately reduced systolic function

• Inadequate coaptation of the mitral leaflets resulting in moderate-to-severe mitral insufficiency

• There is a thin 8mm-long mobile echodensity on the aortic side of the aortic valve of unclear etiology, unusual appearance for endocarditis or thrombus.

• Sclerodegenerative valve disease with mild aortic insufficiency

• Mild pulmonary hypertension

• Biatrial enlargement

Cardiology suspected that her cardiomyopathy was secondary to alcohol abuse, but due to the mobile mass on the aortic valve, there was suspicion for endocarditis. Blood cultures were drawn, patient was started on IV antibiotics, and a heparin drip.

Throughout her inpatient stay, the patient remained afebrile and blood cultures were negative. What’s the diagnosis?

LAMBL’S EXCRESCENCE

Lambl’s excrescences (LE) are thin, filiform strands of connective tissue found on the closure lines of valves.  Minor endothelial damage promotes thrombus formation and deposition of layers of mucopolysaccharide matrix. They are often seen as an incidental finding on transesophageal echocardiogram and are more commonly observed on the mitral valve than the aortic valve.

In one prospective review of healthy volunteers undergoing TEE, there were similar rates of cardioembolic disease between groups with LEs and those without. Additionally, they observed that aspirin and warfarin use did not alter prevalence or cardioembolic risk of LEs. In another study, LE were seen in up to 39% of elderly patients undergoing TEE for suspected cardiogenic embolic stroke. While they are typically small (1x10mm) they have the potential of embolization, with case reports attributing larger LEs to stroke or MI.

In the absence of clear evidence that they cause cardioembolic disease, Lambl’s excrescences as an isolated, incidental finding do not warrant prophylactic antithrombic therapy. More research is needed to determine the clinical significance of LEs.

Case Conclusion

The patient received a TEE two days later to further evaluate this and it was determined to be Lambl's excrescence, not endocarditis. Further ischemic workup was recommended by cardiology with nuclear stress test and medical optimization as an outpatient.

Faculty Reviewer: Dr. Alyson McGregor

References

1. Chu A, Aung TT, Sahalon H, Choksi V, Feiz H. Lambl’s Excrescence Associated with Cryptogenic Stroke: A Case Report and Literature Review. Am J Case Rep. 2015; 16:876-81.

2. Nakahira J, Sawai T, Kutsumata T, Imanaka H Minami T. Lambl’s excrescence on aortic valve detected by transesophageal echocardiography. Anesth Analg. 2008 June;106(6):1639-40.

3. Roldan CA, Schevchuck O, Tolstrun K, Roldan PC, Macias L, Qualls CR, Greene ER, Hayek R, Charlton GA, Sibbitt WL Jr. Lambl’s Excrescences: Association with Cerebrovascular Disease and Pathogenesis. Cerebrovasc Dis. 2015;40(1-2): 18-27.