Libman–Sacks Endocarditis in Triple-Positive Antiphospholipid Syndrome Following Switch from Warfarin to Rivaroxaban: Improvement After Reinstitution of Warfarin and Escalation of Immunosuppression

Triple-positive antiphospholipid syndrome (APS) represents a high-risk serologic phenotype associated with recurrent thrombosis and systemic lupus erythematosus (SLE). Direct oral anticoagulants (DOACs), particularly rivaroxaban, have demonstrated inferior outcomes compared with vitamin K antagonists in this population. We report a case of a patient with long-standing SLE and persistently triple-positive APS who developed Libman–Sacks endocarditis following a switch from warfarin to rivaroxaban. The patient had biopsy-proven class V lupus nephritis and had remained clinically stable on long-term warfarin therapy for several years. Transthoracic echocardiography demonstrated underlying rheumatic mitral valve disease with newly developed mobile vegetations measuring 10-15 mm. Blood cultures obtained prior to antibiotic exposure were negative, and inflammatory markers were not suggestive of infection. Rivaroxaban was discontinued, and warfarin was reinstated with bridging therapy. Prednisolone (40 mg daily) was initiated, and follow-up echocardiography demonstrated a reduction in vegetation size with clinical improvement. This case highlights a temporal association between rivaroxaban use and valvular thrombotic lesions in high-risk APS. Improvement was likely multifactorial, reflecting combined effects of anticoagulation, escalation of immunosuppression, and underlying valvular disease. These findings support current recommendations favoring vitamin K antagonists over DOACs in patients with triple-positive APS.

Cite this article as: Saleh I, Salman S, Alkady A, Saqabi FA. Libman–Sacks endocarditis in triple-positive antiphospholipid syndrome following switch from warfarin to rivaroxaban: improvement after reinstitution of warfarin and escalation of immunosuppression. Eur J Rheumatol. 2026, 13(2), 0009, doi: 10.5152/ eurjrheum.2026.26009.