To the editor:
The incidence of hemoperitoneum in patients in dialysis varies from 6% to 57% in postmenopausal women.1 The appearance of blood in the peritoneum can be related either with renal disease and dialysis or not.
Libman-Sacks endocarditis was first described in 1924. It is characterized by vegetating lesions implanted on valvular surfaces and is closely related to the presence of anti-phospholipid antibodies.2,3 We report a patient in peritoneal dialysis, who developed Libman-Sacks endocarditis and hemoperitoneum.
The patient is a 51 year-old woman with CRF secondary to IgA mesangial nephropathy, who initiated renal replacement therapy by peritoneal dialysis in May of 2006. She had a history of natural interruption of a pregnancy on the sixth month in 1981 and thrombosis in arteriovenous fistula in 1988.
In August of 2006 she was admitted because of a clinical picture compatible with stroke (facial palsy and dysarthria). During the in-hospital stay an endocarditis on native aortic valve was detected y heart ultrasound. Doppler echocardiography is considered elective for the diagnosis of endocarditis. The frequency of valvular involvement is 18-50%.4 The frequency of valvular disease detection is even higher on transesophageal echocardiography.5 In the reported case thoracic echocardiography showed an enlarged vegetation emerging from the left coronary veil that caused mild aortic regurgitation (fig. 1).
The patient had no fever. On physical exam no cardiac murmurs were heard. Blood cultures, viral serologies, and ANA and anti- DNA antibodies were negative.Lupus anticoagulant was positive in two occasions. Cranial magnetic resonance imaging disclosed images compatible with cerebral infarctions in the frontal and left occipital lobes, and in the right cerebellar hemisphere, probably due to embolization from endocardial vegetation. The electrocardiogram showed also subendocardial ischemia probably related to microemboli. Libman-Sacks endocarditis is usually asymptomatic, although the vegetations fragments can produce distant emboli6 as in this patient. She additionally presented an isolated episode of mild hemoperitoneum in the same context as the embolisms with unremarkable ultrasound findings. The commonest causes of hemoperitoneum are: of gynecological origin, after transplantation, with catheter replacement or related to an increase in physical activity. Mild bleeding can also appear in pancreatitis, peritoneal sclerosis and after performing a colonoscopy.
Broad-spectrum antibiotic therapy was administered with no improvement in echocardiographic images. Anticoagulant treatment with warfarine was initiated. The hemoperitoneum was not a contraindication as it was very small.
The approach to the patient with valvular disease includes prophylaxis of endocarditis, anti-platelet or anticoagulant therapy, and surgical valvular replacement in selected cases with severe valvular impairment. The role of steroids in the evolution of the valvular disease is not yet completely known.7
We witnessed the vegetation disappearance with anticoagulant therapy on echocardiographic control.
In this case, the natural pregnancy interruption, the history of thrombosis, the positive lupus anticoagulant and the excellent evolution with anticoagulant therapy would confirm thise infrequent diagnosis.
