Intracardiac thrombus and multiple venous thromboses revealing focal segmental glomerulosclerosis

Nephrotic syndrome is associated with a hypercoagulable state, leading to an increased risk of potentially severe thromboembolic events. Although venous thromboses predominantly involve the renal veins and deep veins of the lower extremities, intracardiac thrombosis remains an exceptionally rare manifestation, particularly as the initial presenting feature. We report the case of a 51-year-old woman with a history of schizophrenia and recent cholecystectomy, who was admitted for lower-limb edema and hematuria of two weeks' duration. Computed tomography of the chest, abdomen, and pelvis revealed multiple thrombotic events, including deep vein thrombosis of the lower extremities, partial thrombosis of the left renal vein, and a left ventricular intracardiac thrombus measuring 23 × 20 mm. Laboratory investigations demonstrated nephrotic syndrome with a urine protein-to-creatinine ratio of 10 g/g and hypoalbuminemia of 23 g/L, associated with stage 2 acute kidney injury. Immunological testing was negative, including anti-neutrophil cytoplasmic antibodies (ANCA) and anti-phospholipase A2 receptor (anti-PLA2R) antibodies. Kidney biopsy established the diagnosis of focal segmental glomerulosclerosis. Management consisted of therapeutic anticoagulation, diuretic therapy, and corticosteroid treatment, resulting in progressive clinical and biological improvement. This case highlights the exceptional occurrence of a left ventricular thrombus associated with multiple venous thromboses as the presenting manifestation of focal segmental glomerulosclerosis. It underscores the importance of systematically investigating underlying glomerular disease in patients presenting with multiple or unusual thrombotic events, particularly in the presence of significant proteinuria.