RIGHT-VENTRICULAR THROMBUS AFTER PACEMAKE R IMPLANTATION IN A PATIENTWITH SECONDARY ANTIPHOSPHOLIPID SYNDROME

History and admission findings: An 85-year-old woman was admitted beca use of frequent syncopes. She also reported slight weight loss, cough and dyspnoea. Chest auscultation revealed slight strider and a cardiac arrhythmia, with an irregular ventricular rate between 120 and 140 be ats/min. Investigations: She had a thrombocytopenia (96 platelets/nl), and the ECG and long-term monitoring showed a tachyarrhythmia with at rial fibrillation, a bifascicular block (left anterior hemiblock and r ight bundle branch block), as well typical signs of sick-sinus syndrom e with short periods of bradycardic sinus rhythm and pauses of up to 6 s on rhythm change. Echocardiography indicated moderately reduced lef t ventricular function. Chest radiogram revealed tracheal narrowing by a retrosternal goitre. No evidence of tumour was found on bronchoscop y. Diagnosis, treatment and course: A WI pacemaker was implanted. When the platelet: count dropped to 30/nl idiopathic thrombocytopenic purp ura was suspected, but administration of high doses of corticoids and immunoglobulin was without effect. Another echocardiogram, performed b ecause of chest pain suspicious of pulmonary embolism, revealed a larg e bowl-shaped right ventricular thrombus with floating parts. Demonstr ation of anticardiolipin antibodies established the diagnosis of antip hospholipid syndrome (APLS), thought to be secondary to thyroid cancer suspected from the computed tomography. The patient died 2 months lat er from recurrent pulmonary embolism and progressive liver failure. Au topsy revealed a not previously diagnosed tracheal carcinoma with meta stases to the thyroid, as well as haematogenous metastatic foci within the right ventricular thrombus. Interpretation: In case of thrombocyt openia of uncertain aetiology APLS should be included in the different ial diagnosis, even in the absence of any early or acute thrombosis, I f anticardiolipin antibodies and/or lupus anticoagulant are demonstrat ed, malignant neoplasm should be considered in addition to autoimmune disease.