Differential Diagnosis for Patient with Ca Prostate, Normal Echo, and Multifocal Infarcts

• Single Most Likely Diagnosis
  • Tumor Embolism: This is a likely diagnosis given the patient's history of prostate cancer (Ca prostate) and the presence of multifocal infarcts. Tumor embolism occurs when tumor cells break away from the primary site, travel through the bloodstream, and lodge in smaller vessels, causing infarcts. The normal echo (echocardiogram) suggests that the cardiac function is preserved, but it does not rule out the possibility of tumor emboli originating from the prostate cancer.
• Other Likely Diagnoses
  • Disseminated Intravascular Coagulation (DIC): Patients with cancer, including prostate cancer, are at an increased risk of developing DIC, a condition characterized by both widespread clotting and bleeding. The multifocal infarcts could be a result of the clotting aspect of DIC.
  • Non-bacterial Thrombotic Endocarditis (NBTE): Also known as marantic endocarditis, NBTE is associated with malignancies, including prostate cancer. It involves the formation of small sterile vegetations on heart valves, which can embolize and cause infarcts in various organs.
• Do Not Miss Diagnoses
  • Infective Endocarditis: Although the echo is reported as normal, infective endocarditis can sometimes present with minimal or no visible vegetations on initial echocardiography. It's crucial to consider this diagnosis due to its high morbidity and mortality if left untreated.
  • Atrial Fibrillation with Emboli: Even if the initial echo appears normal, atrial fibrillation can lead to the formation of thrombi in the heart, which then embolize and cause infarcts. The absence of a clear cardiac source on the echo does not entirely rule out this possibility, especially if the arrhythmia is paroxysmal.
• Rare Diagnoses
  • Choriocarcinoma with Emboli: Although rare, choriocarcinoma (a type of germ cell tumor) can produce human chorionic gonadotropin (hCG), leading to hypercoagulability and an increased risk of thromboembolic events, including multifocal infarcts.
  • Paraneoplastic Syndromes: Certain paraneoplastic syndromes associated with prostate cancer can lead to coagulopathy or vasculitis, resulting in multifocal infarcts. These are rare but should be considered in the differential diagnosis when common causes have been ruled out.