CASE REPORT Nonbacterial Thrombotic Endocarditis in a Child With Non-Hodgkin’s Lymphoma Norliza Ali • Igor Konstantinov • John A. Heath • Krishna Bhagwat • Michael Cheung Received: 22 October 2011 / Accepted: 19 December 2011 / Published online: 12 February 2012 Ó Springer Science+Business Media, LLC 2012 Abstract The diagnosis of nonbacterial thrombotic endocarditis (NTBE) is rarely made during life. This report describes a child who had high-grade non-Hodgkin’s lymphoma with NTBE and multiple systemic embolism. The transthoracic echocardiographic findings of mitral valve leaflet vegetations and progressive regurgitation led to surgical resection of the vegetations. A high index of suspicion is needed when a clinician is faced with a patient who has malignancy, systemic embolic phenomena, and persistent negative blood cultures. Keywords Non-bacterial thrombotic endocarditis Á Non-Hodgkin lymphoma Á Transthoracic echocardiography Case History An 8-year-old girl, who was previously well, presented with a 10-day history of high-grade fever associated with non- specific symptoms of lethargy, cough, sore throat, inter- mittent rash, and joint pain. Her physical examination was unremarkable. A full blood count showed mild anemia, a hemoglobin (Hb) level of 89 g/l, and an elevated white blood cell (WBC) count of 20.5 9 10 9 /l with a neutrophilia level of 17.7 9 10 9 /l. The inflammatory markers were raised, with an erythrocyte sedimentation rate (ESR) of 135 mm/h and a C-reactive protein (CRP) level of 223 mg/l. The patient was initially thought to have atypical Kawasaki disease, and two courses of intravenous immu- noglobulin were administered at a dose of 2 gm/kg. Per- sistence of fever and a weakly positive anti nuclear antibody titer (1:160, speckled) led to a differential diag- nosis of juvenile idiopathic arthritis, which was treated with corticosteroids. The girl was discharged after an initial improvement but was readmitted to the hospital 3 days later with persistent fever, increasing respiratory distress, and significant cervical lymphadenopathy. The total WBC count at this stage was markedly elevated to 84 9 10 9 /l, with a further rise in inflammatory markers (ESR, [ 170 mm/h; CRP, [ 270 mg/l). A computed tomography (CT) scan of the chest showed dif- fuse lymphadenopathy ranging in size from 11 to 18 mm in the supraclavicular, mediastinal, axillary, paraaortic, aorto- caval, and periportal regions. The patient underwent an excisional biopsy of a cervical lymph node and bone marrow aspiration, both of which were positive for CD30? ALK (anaplastic lymphoma kinase)- positive anaplastic large-cell lymphoma, consistent with stage 4 disease. She subsequently experienced multi- organ failure, with significant cardiopulmonary deterioration N. Ali (&) Á M. Cheung Department of Cardiology, Royal Children’s Hospital, Flemington Road, Parkville, VIC 3052, Australia e-mail: drnorliza@yahoo.com I. Konstantinov Á K. Bhagwat Department of Cardiac Surgery, Royal Children’s Hospital, Melbourne, Australia I. Konstantinov Á J. A. Heath Á M. Cheung Department of Paediatrics, University of Melbourne, Parkville, Australia I. Konstantinov Á M. Cheung Heart Research Group, Murdoch Children’s Research Institute, Parkville, Australia J. A. Heath Children’s Cancer Centre, Royal Children’s Hospital, Melbourne, Australia 123 Pediatr Cardiol (2012) 33:843–845 DOI 10.1007/s00246-012-0230-y