Cardiovascular manifestations of hypereosinophilic syndromes

Direct Oral Anticoagulants for Stroke and Systemic Embolism Prevention in Patients with Left Ventricular Thrombus

In recent years, direct oral anticoagulants (DOAC) have accumulated evidence of efficacy and safety in various clinical scenarios and are approved for a wide spectrum of indications. Still, they are currently used off-label for left ventricular thrombus owing to a paucity of evidence. For the same reason, there is a lack of guideline indication as well. Our work is based on an exhaustive analysis of the available literature and provides a structured and detailed update on the use of DOACs in patients with left ventricle thrombus. The safety and efficacy of DOACs were analyzed in particular clinical scenarios. As far as we know, this is the first paper that analyzes DOACs in this approach.

Hypereosinophilic Syndrome Secondary to Ulcerative Colitis and Primary Sclerosing Cholangitis

Hypereosinophilic syndrome (HES) is a rare condition characterized by hypereosinophilia in peripheral blood or tissue infiltrate and organ damage. HES has been associated with several diseases, including inflammatory bowel diseases (IBDs), especially ulcerative colitis (UC). In this report, we describe a case of a UC and primary sclerosing cholangitis patient who was diagnosed with HES and severe cardiovascular and neurological injury. During hospitalization, an extensive diagnostic workup was performed and secondary causes of hypereosinophilia were ruled out. The patient was treated with glucocorticoids and full anticoagulation with significant clinical improvement and a marked reduction in the eosinophil count. In the literature, hypereosinophilia in the IBD population has been related to the severity of the disease and worse prognosis. The high index of clinical suspicion and the accurate diagnosis of HES are essential to avoid delay in therapy and prevent complications.

Systemic thrombo-embolic events in a middle-aged male with Loeffler endocarditis without peripheral eosinophilia-a case report

BACKGROUND

Loeffler-endocarditis (LE) is considered a chronic restrictive cardiomyopathy and manifestation of eosinophilic myocarditis characterized by eosinophilic infiltration. LE is a rare underdiagnosed disease and associated with high morbidity and mortality.

CASE PRESENTATION

We report a case of a 46-year-old man suffering from LE associated with thromboembolic events without peripheral eosinophilia. The patient presented with typical clinical signs of acute onset of limb ischaemia, predominantly on the right limb, indicating immediate iliacal thrombectomy and due to a severe compartment syndrome additional fasciotomy. Total occlusion also of left popliteal artery suggesting an impaired chronic and aggravated impaired perfusion indicated also urgent left sided revascularization. Subsequent echocardiography revealed severe left ventricular dysfunction with a striking amount of spontaneous echo-contrast, noticeable in the left ventricular cavity. Furthermore the initial CT scan demonstrated asymptomatic left kidney- and brain infarctions. Diagnostic workup including endomyocardial biopsy (EMB) of the left ventricle, uncovered an underlying LE without peripheral eosinophilia.

CONCLUSIONS

This case demonstrates and highlights the findings, treatment and outcome of a patient with LE and associated thrombo-embolic events without peripheral eosinophilia and emphazises the importance of awareness for LE in patients presenting with an acute cardiac decompensation and thrombo-embolic events. EMB should be performed early in unstable patients unsuitable for cardiovascular magnetic resonance imaging.

At the Heart of Eosinophilic Granulomatosis with Polyangiitis: into Cardiac and Vascular Involvement

PURPOSE OF REVIEW

To provide an overview of existing literature on pathogenetic and clinical aspects of cardiac and vascular involvement in eosinophilic granulomatosis with polyangiitis (EGPA).

RECENT FINDINGS

In EGPA, cardiac and vascular involvement are more common than previously thought. However, no international recommendations on the topic are available yet. Herein, we summarize the existing evidence on the topic and propose a diagnostic approach for cardiac involvement in EGPA. The prevalence of cardiovascular involvement in patients with EGPA varies greatly among published studies, ranging between 3.1-18.7% for occlusive arterial disease, 5.8-30% for venous thrombosis and 17-92% for heart involvement. Cardiac involvement in EGPA is associated with high mortality even though manifestations are heterogeneous. In principle, every anatomical structure of the heart can be involved, and EGPA-related heart disease may be completely asymptomatic at first. A careful diagnostic work-up for early detection and prompt treatment initiation is therefore required. While cardiac manifestations are more common in anti-neutrophil cytoplasmic antibodies (ANCA)-negative patients, arterial and venous thrombotic events are not linked to ANCA status but correlate closely with disease activity and accumulate at disease onset. Thrombotic events (mainly venous) are considerably more frequent in EGPA than in the general population contributing substantially to morbidity and highlighting the importance of developing specific prevention strategies for patients who are diagnosed with EGPA.

Rethinking blood eosinophil counts: Epidemiology, associated chronic diseases, and increased risks of cardiovascular disease

Background

The distribution and determinants of blood eosinophil counts in the general population are unclear. Furthermore, whether elevated blood eosinophil counts increase risk for cardiovascular disease (CVD) and other chronic diseases, other than atopic conditions, remains uncertain.

Objective

We sought to describe the distribution of eosinophil counts in the general population and determine the association of eosinophil count with prevalent chronic disease and incident CVD.

Methods

A population-based adult cohort was followed from January 1, 2006, to December 31, 2020. Electronic health record data regarding demographic characteristics, prevalent clinical characteristics, and incident CVD were extracted. Associations between blood eosinophil counts and demographic characteristics, chronic diseases, laboratory values, and risks of incident CVD were assessed using chi-square test, ANOVA, and Cox proportional hazards regression.

Results

Blood eosinophil counts increased with age, body mass index, and reported smoking and tobacco use. The prevalence of chronic obstructive pulmonary disease, hypertension, cardiac arrhythmias, hyperlipidemia, diabetes mellitus, chronic kidney disease, and cancer increased as eosinophil counts increased. Eosinophil counts were significantly associated with coronary heart disease (hazard ratio [HR], 1.44; 95% CI, 1.12-1.84) and heart failure (HR, 1.62; 95% CI, 1.30-2.01) in fully adjusted models and with stroke/transient ischemic attack (HR, 1.37; 95% CI, 1.16-1.61) and CVD death (HR, 1.49; 95% CI, 1.10-2.00) in a model adjusting for age, sex, race, and ethnicity.

Conclusions

Blood eosinophil counts differ by demographic and clinical characteristics as well as by prevalent chronic disease. Moreover, elevated eosinophil counts are associated with risk of CVD. Further prospective investigations are needed to determine the utility of eosinophil counts as a biomarker for CVD risk.

The hypereosinophilic syndrome - an unusual cause of myocarditis and cardioembolic strokes

Hypereosinophilic syndrome is a rare disorder characterized by excessive peripheral eosinophilia and eosinophil associated end-organ damage. Clinical presentations are heterogenous and can involve skin, pulmonary, cardiac and neurologic dysfunction. Eosinophilic myocarditis is a life-threatening complication that increases the risk of cardiac microemboli, which can subsequently lead to embolic strokes. Secondary to changes in blood viscosity, impaired clearance of microemboli, impaired cerebral blood flow, and pro-thrombotic conditions in the setting of hypereosinophilia, infarcts often present in vascular border zone regions. Here we present two cases of cardioembolic strokes involving borderzone regions in the setting of hypereosinophilic syndrome.

Anesthetic Management of a Large Right Ventricular Mass due to Idiopathic Hypereosinophilic Syndrome in a Patient Undergoing Cardiac Surgery, a Case Report

Cardiovascular complications of hypereosinophilic syndrome (HES) constitute a significant source of morbidity and mortality, with heart involvement found in approximately 40%-80% of patients. In patients with right heart failure due to an intracardiac mass, induction of general anesthesia poses numerous challenges. The effects of positive pressure ventilation on right ventricular (RV) physiology can quickly lead to precipitous cardiovascular collapse, which increases the importance of maintaining adequate negative pressure ventilation strategies. Current strategies involve awake femoro-femoral cannulation with partial vs full flow femoro-femoral cardiopulmonary bypass (CPB), but both methods increase the risk of intraoperative blood loss due to systemic heparinization prior to sternotomy. In this case report, the authors describe an approach to anesthetizing a patient with severe right ventricular heart failure due to an intracardiac mass due to idiopathic HES. This approach involves femoral cannulation prior to induction of general anesthesia, airway topicalization, inhalational induction with fiberoptic intubation, and sternotomy with aortic/bicaval cannulation before paralysis.

Case report: Application of non-VKA oral anticoagulants in patient of idiopathic hypereosinophilic syndrome with intracardiac thrombus

Idiopathic hypereosinophilic syndrome (IHES) is a rare but life-threatening disease related to a group of myeloproliferative disorders characterized by prolonged eosinophilia of unknown cause and inflammatory damage to multiple organs. Here, we present a 44-year-old female patient complaining of shortness of breath and palpitations for 1 month. Her history and presentation were unremarkable, except for a 3-years history of rheumatoid arthritis treated with ibuprofen (0.3 g per day). Initial examination showed heart rate (HR) 120 bpm, respiratory rate (RR) 20 bpm, temperature (T) 36°C, blood pressure (BP) 130/70 mmHg, ventricular gallop rhythm, rales at the lung bases, soft abdomen, nonpalpable liver and spleen, and slight edema in both lower extremities. Bone marrow aspirate and biopsy confirmed the diagnosis of IHES, while cardiac MRI showed intracardiac thrombus. The symptoms of shortness of breath and palpitation disappeared, the eosinophil counts in routine blood tests were normal, and the thrombus in the cardiac cavity gradually disappeared after combined therapy of anti-hypereosinophilic, anti-coagulant and anti-heart failure treatments.

Mepolizumab Reduces Hypereosinophilic Syndrome Flares Irrespective of Blood Eosinophil Count and Interleukin-5

BACKGROUND

Mepolizumab, an anti-interleukin-5 (IL-5) antibody, reduces disease flares in patients with hypereosinophilic syndrome (HES). Factors predicting treatment response are unknown.

OBJECTIVE

To assess mepolizumab efficacy by baseline blood eosinophil count (BEC) and serum IL-5 level in patients with HES.

METHODS

This post hoc analysis used data from the phase III study assessing mepolizumab in patients with HES (NCT02836496). Patients 12 years old or older, with HES for 6 or more months, 2 or more flares in the previous year, and BEC ≥1,000 cells/μL at screening were randomized (1:1) to 4-weekly subcutaneous mepolizumab (300 mg) or placebo, plus baseline HES therapy, for 32 weeks. The proportion of patients experiencing 1 or more flares (wk 32), annualized flare rate, and proportion of patients with change from baseline in Brief Fatigue Inventory (BFI) item 3 (wk 32), were analyzed by baseline BEC (<1500/≥1500 to <2500/≥2500 cells/μL). Flare outcomes were assessed by baseline serum IL-5 (<7.81/≥7.81 pg/mL).

RESULTS

Across baseline BEC subgroups, mepolizumab reduced the proportion of patients experiencing 1 or more flares by 63% to 90% and flare rate by 58% to 84% (treatment-by-eosinophil interaction P = .76 and P = .90, respectively); patients had improved BFI item 3 score with mepolizumab versus placebo (cells/μL: <1,500: 54% vs 37%; ≥1,500 to <2,500: 47% vs 31%; ≥2,500: 61% vs 0%; treatment-by-eosinophil interaction P = .42). Most patients had undetectable baseline serum IL-5 levels; among these, mepolizumab versus placebo reduced the proportion of patients with 1 or more flares (77%) and flare rate (67%).

CONCLUSIONS

Mepolizumab was efficacious in the patients with HES studied, irrespective of baseline BEC. Undetectable IL-5 levels should not preclude mepolizumab treatment.

Society for Cardiovascular Magnetic Resonance 2021 cases of SCMR and COVID-19 case collection series

The Society for Cardiovascular Magnetic Resonance (SCMR) is an international society focused on the research, education, and clinical application of cardiovascular magnetic resonance (CMR). "Cases of SCMR" is a case series hosted on the SCMR website ( https://www.scmr.org ) that demonstrates the utility and importance of CMR in the clinical diagnosis and management of cardiovascular disease. The COVID-19 Case Collection highlights the impact of coronavirus disease 2019 (COVID-19) on the heart as demonstrated on CMR. Each case in series consists of the clinical presentation and the role of CMR in diagnosis and guiding clinical management. The cases are all instructive and helpful in the approach to patient management. We present a digital archive of the 2021 Cases of SCMR and the 2020 and 2021 COVID-19 Case Collection series of nine cases as a means of further enhancing the education of those interested in CMR and as a means of more readily identifying these cases using a PubMed or similar literature search engine.

Eosinophilic Myocarditis: An Often-Overlooked Diagnosis in Patients Presenting with Heart Failure

Introduction. Hypereosinophilic syndrome (HES) is a rare disease characterized by unexplained peripheral eosinophilia along with evidence of end-organ damage. Cardiac involvement is the most life-threatening consequence and is frequently underreported with a prevalence of around 5%. The gold standard for diagnosis is myocardial biopsy, but less-invasive imaging such as cardiac MR (CMR) has been frequently used to help with the diagnosis. We are presenting a unique case of a patient diagnosed with Eosinophilic myocarditis (EM) supported by CMR with rapid improvement after starting steroid treatment. Case Presentation. A 67-year-old African American female with extensive cardiovascular disease history presenting with chest pain was diagnosed with EM secondary to hypereosinophilic syndrome (HES). Lab workup revealed absolute eosinophils of 4.70 × 10³/μL (normal 0–0.75 × 10³/μL). Transthoracic echocardiography showed mild reduction in left ventricular function and a large obliterating thrombus in the right ventricular apex. CMR showed increased signal intensity at the left ventricular and right ventricular apex, consistent with myocardial edema. Subsequently, the patient was placed on dexamethasone 10 mg daily with significant symptomatic improvement. Discussion. EM is a rare complication of hypereosinophilic syndrome and can mimic common cardiovascular diseases such as acute exacerbation of heart failure or myocardial infarction. A high index of suspicion is essential especially in the setting of suggestive lab workup. CMR is a promising noninvasive and cost-effective alternative for myocardial biopsy in diagnosis.

Case Report: An Unusual Presentation of Cardiovascular Involvement in Eosinophilic Granulomatosis With Polyangiitis

Background

Because eosinophilic granulomatosis with polyangiitis (EGPA) is so rare and the symptoms so varied, it can be a challenge to get a correct diagnosis in clinical practice. Cardiovascular involvement is the main cause of death of EGPA. We are the first to report of cardiac magnetic resonance (CMR) findings about right-sided heart involvement in EGPA.

Patient Findings

The initial abnormalities detected by CMR were Löffler endocarditis with extensive thrombosis and left ventricular (LV) dysfunction. After active treatment, LV systolic function recovered and endocarditis with thrombosis significantly improved, but there was rapidly progressive pulmonary hypertension, enlargement of right atrium and right ventricle and persistent right-sided heart failure. The patient eventually died of sudden cardiac death 6 months after hospital discharge.

Conclusions

Löffler endocarditis and right-sided heart involvement are both rare presentations in patients with EGPA. CMR is a reliable non-invasive tool to precisely and comprehensively assess cardiovascular involvement in EGPA.

A Unique Case of Cardiac Hypereosinophilia With Recurrent Valve Thrombosis After Mechanical Mitral Valve Replacement in the Setting of a Supratherapeutic International Normalized Ratio

Hypereosinophilia (HES) is a rare, but highly fatal, disease that results in excess eosinophils causing multiorgan damage, mainly manifesting as extensive inflammation contributing to fibrosis. Notably, cardiac involvement occurs in almost half the cases and can often lead to thrombus development. This is a unique case of HES contributing to recurrent cardiac thrombus formation on a mechanical mitral valve in the setting of a patient who had a supratherapeutic international normalized ratio (INR) while on coumadin. The rarity of this case is also displayed in the patient’s negativity for one of the fusion genes that are highly suggestive of cardiac HES, the demographics of her female gender, and her first objective sign being T-wave inversions versus the usual heart failure signs and symptoms. This case raises awareness of the disorder but also the importance of keeping its potential exacerbations on the differential, even in the setting of atypical presentations. With this, it also begs the question of whether coumadin is the proper anticoagulant of choice in these patients and whether other parameters should be considered.

Microbubble Enhanced Echocardiography in Current Cardiology Practice

Contrast-enhanced ultrasound imaging is a radiation-free clinical diagnostic tool that uses biocompatible contrast agents to enhance ultrasound signal, in order to improve image clarity and diagnostic performance. Ultrasound enhancing agents (UEA), which are usually gas microbubbles, are administered intravenously either by bolus injection or continuous infusion. UEA increase the accuracy and reliability of echocardiography, leading to changes in treatment, improving patient outcomes and lowering overall health care costs. In this review we describe: (1) the current clinical applications of ultrasound enhancing agents in echocardiography, with a brief review of the evidence underlying each of these applications; (2) emerging diagnostic and therapeutic applications of microbubble enhanced echocardiography (MEE), which rely either on the specific properties and composition of ultrasound enhancing agents or on the technical advances of clinical ultrasound systems; and (3) safety of MEE.

Rare Case of a Young Male Presented with Abdominal Pain, Solid Colon Tumors, and Eosinophilia, Followed by Tremendous Thromboembolic Complications and Eventually Diagnosed with Idiopathic Hypereosinophilic Syndrome

Hypereosinophilic syndrome (HES) is a rare condition characterized by profound peripheral eosinophilia and various organ dysfunction. Diagnostic criteria and classification of this challenging medical entity changed over time. Elevated absolute eosinophil count with extensive tissue infiltration and signs of organ damage of unknown origin is termed idiopathic HES. Hypereosinophilia is a highly hypercoagulable state; thus, a variety of thromboembolic complications may occur. Only a few reports of idiopathic HES patients with different forms of thrombosis are being published. We document a case of a young male presented with persistent abdominal pain with two eosinophilic colon tumors. The patient suffered from phlegmasia cerulea dolens and portal vein thrombosis, followed by pulmonary embolism and overt disseminated intravascular coagulation (DIC). Corticosteroids successfully reduced and controlled eosinophil level while skilled anticoagulation and supportive management overcome DIC-associated complications.

MRI as an Effective Tool for the Diagnosis and Monitoring of Leffler Endocarditis at the Stages of Longitudinal Observation

Hypereosinophilic syndrome (HES) is an extremely rare disease that is not always diagnosed, and the lack of statistic data does not let to determine its real incidence. Among patients men predominate, the ratio of men and women is 9: 1, the most vulnerable age is from 20 to 50 years. The familial hypereosinophilia is inherited disease of autosomal dominant type. Two-year mortality was recorded in half of the cases of Leffler’s endocarditis with progressive fibrosis due to heart failure and thromboembolic complications. Leffler’s endocarditis and endomyocardial fibrosis as components of restrictive cardiomyopathy are accompanied by eosinophilia. The story of the discovery of eosinophils is closely connected to the name of Paul Ehrlich; the further idea of tracing the connection between eosinophilia and the involvement of the heart and other organs belongs to Leffler. In the presence of Leffler’s syndrome, the probability of thrombosis in the heart cavities and determination of the stage of the disease were analyzed by longitudinal observation using cardiac MRI. The described clinical case of Leffler syndrome in a young man in real clinical practice clearly demonstrates the difficulties of diagnosis in the outpatient phase, need in interdisciplinary approach in the work of the team “heart team” during the hospital period, the role and importance of long-term cardiac MRI monitoring of the selected optimal therapy. Leffler’s syndrome in real clinical practice requires from physicians of various specialties, including family physicians, knowledge of etiology, pathogenesis, clinical masks of disease manifestation and tactics of patient management in the outpatient phase. MRI of the heart remains the “gold standard” for diagnosis and longitudinal monitoring of patients with Leffler syndrome.

Eosinophilic Myocarditis: A Challenging Diagnosis

Eosinophilic myocarditis (EM) is a rare subtype of myocarditis that is characterized by eosinophilic infiltration of the myocardium and is associated with peripheral eosinophilia in most cases. The diagnosis is suspected in the presence of acute myocarditis and peripheral eosinophilia and is usually confirmed by endomyocardial biopsy (EMB) before starting steroid therapy. Here, we present a case of severe idiopathic eosinophilic myocarditis in a young man with a history of asthma and peripheral eosinophilia. He was treated with high-dose steroids despite negative EMB, and we noted a dramatic improvement in cardiac function. Our case highlights the importance of cardiac magnetic resonance (CMR) and clinical judgment in establishing the diagnosis of EM irrespective of the histopathologic result.

Hypereosinophilic syndrome presenting as acute ischemic stroke, myocardial infarction, and arterial involvement: A case report

BACKGROUND

Simultaneous cerebral and myocardial infarction with arterial involvement has not been reported in hypereosinophilic syndrome (HES). Here, we report a patient with HES that was also associated with acute ischemic stroke, myocardial infarction, and arterial involvement of the left common carotid artery, vertebral arteries, posterior cerebral artery, and coronary artery.

CASE SUMMARY

A 64-year-old male patient was admitted with headache and right lower extremity weakness. Laboratory tests indicated eosinophilia. Brain magnetic resonance imaging (MRI) showed bilateral and multiple acute infarcts in the border zones. Electrocardiography revealed that T wave was inverted and that the concentration of troponin I was significantly elevated above normal levels. Cardiac echocardiography showed an ejection fraction of 69% with mitral and tricuspid mild regurgitation. Computed tomography angiography detected multiple and localized instances of mild stenosis in the left common carotid artery bifurcation, bilateral vertebral arteries (V5 segment), and the posterior cerebral artery (P2 segment). These were observed together with multiple non-calcified and mixed plaques as well as luminal stenosis in the left circumflex artery, left anterior descending artery, and right coronary artery. The patient was treated with oral methylprednisolone and clopidogrel, after which the absolute eosinophil count fell rapidly to a normal level. After one month, a second brain MRI showed a partial reduction in the size and number of the lesions.

CONCLUSION

HES can masquerade as ischemic stroke, myocardial infarction, and arterial vascular involvement. The patient reported here recovered very quickly when his eosinophil blood count returned to normal. Early diagnosis and rapid reduction of eosinophils may lead to a good prognosis.

Association Between Baseline Therapy and Flare Reduction in Mepolizumab-Treated Patients With Hypereosinophilic Syndrome

Background

Current standard-of-care treatments for hypereosinophilic syndrome (HES) include oral corticosteroids (OCS) and immunosuppressive/cytotoxic (IS/CT) therapies. The anti-IL-5 monoclonal antibody mepolizumab has also recently been approved for patients with this disease. The objective of this analysis was to assess the relationship between baseline therapy and flare reduction in patients with HES treated with mepolizumab, using data from the Phase III 200622 study (NCT02836496).

Methods

In the double-blind, parallel-group 200622 study, eligible patients were ≥12 years old and had HES for ≥6 months, ≥2 flares in the previous 12 months, blood eosinophils ≥1000 cells/μL at screening and ≥4 weeks’ stable HES therapy. Patients were randomised (1:1) to receive mepolizumab 300 mg subcutaneously or placebo every 4 weeks for 32 weeks plus their existing HES therapy. This post hoc, descriptive analysis assessed the effect of baseline HES therapy [IS/CT (± OCS), OCS No IS/CT, and No IS/CT/OCS] on the proportion of patients with ≥1 flare during the study period, the annualised rate of flares, time to first flare, and the proportion of patients with ≥1 flare during Weeks 20─32, with mepolizumab versus placebo.

Results

Mepolizumab treatment was associated with a decrease in the proportion of patients who experienced ≥1 flare during the study period in all baseline therapy groups versus placebo (32–96% reduction). Similarly, the probability of a flare was lower with mepolizumab (14.3–31.4%) than placebo (35.7–74.1%) in all baseline therapy groups, as was the annualised flare rate (0.22–0.68 vs 1.14–1.62). The proportion of patients who experienced ≥1 flare during Weeks 20–32 was reduced with mepolizumab versus placebo for all baseline therapy groups (55–85% reduction). For all endpoints, the greatest effect of mepolizumab treatment was seen in the IS/CT (± OCS) group.

Conclusions

Patients with poorly controlled HES are likely to achieve clinical benefit with mepolizumab in terms of flare reduction, regardless of their baseline therapy.

Clinical Trial Registration

(https://clinicaltrials.gov/ct2/show/NCT02836496).

Overview of Restrictive Cardiomyopathies

Restrictive cardiomyopathy (RCM) includes a heterogeneous group of diseases that cause increased myocardial stiffness, leading to impaired ventricular relaxation and severe diastolic dysfunction. Given that it is the least common type of cardiomyopathy, it can be a diagnostic challenge due to its varied pathogenesis, clinical presentation, and diagnostic evaluation. In this review, we provide an overview of different etiologies of RCM and examine the diagnostic and treatment approaches for various types.

Increased Circulating Cell-Free DNA in Eosinophilic Granulomatosis With Polyangiitis: Implications for Eosinophil Extracellular Traps and Immunothrombosis

Background

Endogenous DNA derived from nuclei or mitochondria is released into the blood circulation as cell-free DNA (cfDNA) following cell damage or death. cfDNA is associated with various pathological conditions; however, its clinical significance in antineutrophil cytoplasmic antibody-associated vasculitis (AAV) remains unclear. This study aimed to evaluate the clinical significance of cfDNA in AAV.

Methods

We enrolled 35 patients with AAV, including 10 with eosinophilic granulomatosis with polyangiitis (EGPA), 13 with microscopic polyangiitis, and 12 with granulomatosis with polyangiitis. Serum cf-nuclear DNA (cf-nDNA) and cf-mitochondrial DNA (cf-mtDNA) levels were measured by quantitative polymerase chain reaction before and after the initiation of immunosuppressive therapy. Tissue samples from EGPA patients were examined by immunofluorescence and transmission electron microscopy. The structure of eosinophil extracellular traps (EETs) and neutrophil extracellular traps (NETs) and stability against DNase were assessed in vitro. Platelet adhesion of EETs were also assessed.

Results

Serum cf-nDNA and cf-mtDNA levels were significantly higher in AAV than in healthy controls, with the highest levels in EGPA; however, serum DNase activities were comparable among all groups. cf-nDNA and cf-mtDNA decreased after treatment and were associated with disease activity only in EGPA. Blood eosinophil count and plasma D-dimer levels were significantly correlated with cf-nDNA in EGPA and cf-mtDNA. EGPA tissue samples showed lytic eosinophils and EETs in small-vessel thrombi. The structure of EETs showed bolder net-like chromatin threads in vitro and EETs showed greater stability against DNase than NETs. EETs provided a scaffold for platelet adhesion.

Conclusion

cfDNA was increased in EGPA, associated with disease activity. The presence of DNase-resistant EETs in small-vessel thrombi might contribute to higher concentration of cfDNA and the occurrence of immunothrombosis in EGPA.

Helicobacter pylori infection manifesting as Hypereosinophilic syndrome and immune thrombocytopenia complicated by portal vein thrombosis and ischemic colitis

Hypereosinophilic syndromes (HES) are a group of uncommon disorders characterized by persistent eosinophils overproduction which can lead to tissue damage and organs dysfunction secondary to eosinophils tissue infiltration and inflammatory mediators' release. Causes of secondary HES include parasitic infection, some solid tumors, underlying connective tissue disease, allergic conditions and T cell lymphoma. Helicobacter pylori (H. pylori) has been reported only once as a cause of secondary HES in the literature. We report the second case of H. pylori infection in 29-year-old male patient who presents with HES and secondary Immune thrombocytopenic purpura (ITP). This case is different from the first reported case by the presence of HES complication on presentation manifesting as portal vein thrombosis, which was further complicated by ischemic colitis. H, pylori eradication therapy alone was successful in a resolution of hypereosinophilia and platelets recovery without the need of corticosteroids or any other treatment.

"Heart in DRESS": Cardiac Manifestations, Treatment and Outcome of Patients with Drug Reaction with Eosinophilia and Systemic Symptoms Syndrome: A Systematic Review

Cardiac involvement in drug reaction with eosinophilia and systemic symptoms (DS) is rare but associated with high mortality. The aim of this research was to systematically review case reports by PRISMA guidelines in order to synthetize the knowledge of cardiac manifestations of DS. We identified 42 cases from 36 case reports. Women were two times more affected than men. Two-thirds of patients had cardiac manifestation in the initial phase of the disease, while in one-third of cases cardiac manifestations developed later (mean time of 70 ± 63 days). The most common inciting medications were minocycline (19%) and allopurinol (12%). In 17% of patients, the heart was the only internal organ affected, while the majority (83%) had at least one additional organ involved, most commonly the liver and the kidneys. Dyspnea (55%), cardiogenic shock (43%), chest pain (38%), and tachycardia (33%) were the most common cardiac signs and symptoms reported. Patients frequently had an abnormal ECG (71.4%), and a decrease in left ventricular ejection fraction was the most common echocardiographic finding (45%). Endomyocardial biopsy or histological examination at autopsy was performed in 52.4%, with the predominant finding being fulminant eosinophilic myocarditis with acute necrosis in 70% of those biopsied. All patients received immunosuppressive therapy with intravenous steroids, while non-responders were more likely to have received IVIG, cyclosporine, mycophenolate, and other steroid-sparing agents (60%). Gender and degree of left ventricular systolic dysfunction were not associated with outcomes, but short latency between drug exposure and the first DRESS symptom onset (<15 days) and older age (above 65 years) was associated with death. This underscores the potential importance of heightened awareness and early treatment.

IL-5 overexpression induced blood eosinophilia associated progression of cardiac abnormalities

Eosinophilia may be responsible for cardiac injuries of widely varying severity, from acute myocarditis to endomyocardial fibrosis. In this manuscript, we present both the molecular and physiological evidence that promotes eosinophils accumulation in mice heart epicardium and myocardium region of allergen or transgene-insertion of overexpressed IL-15, eotaxin-deficient CD2 promoter driven IL-5 transgenic mice shows abnormal physiological function. Numerous etiologies can lead to severe eosinophilia, but these are mainly represented by hypersensitivity reactions, rheumatological diseases and hypereosinophilic syndrome. Because cardiac involvement may be extremely severe; therefore, we even present echocardiography analysis that indicates IL-15 overexpressed mice showed induced blood eosinophilia associated progression of cardiac abnormalities.

Idiopathic Hypereosinophilic Syndrome Presenting With Embolic Stroke

Hypereosinophilic syndrome is a rare condition characterized by eosinophilia associated with organ damage, most commonly affecting the skin, lung, gastrointestinal, cardiovascular and central nervous system. The idiopathic form is characterized by the absence of other conditions associated with hypereosinophilia such as allergies, infectious, hematological, immunological, endocrine or neoplasm diseases. The authors present a clinical case of a 70-year-old man with no relevant history, who went to the emergency department for neurological deficits and nonspecific chest pain. Laboratory tests revealed marked eosinophilia, elevation of cardiac enzymes with normal electrocardiogram. Computed tomography of the head showed multiple bilateral ischemic lesions. Upon further investigation for the cerebrovascular disease, transesophageal echocardiogram showed a thrombus at the aortic arch, as a probable embolic source. Despite anticoagulant therapy and corticosteroids, the patient's status deteriorated, with multiple successive ischemic strokes and worsening neurological deficits. After a thorough investigation, the diagnosis of idiopathic eosinophilia was established.

Is there an Unnoticed Etiology of Right Atrial Aneurysm?

A 12-year-old male was referred for surgery with the diagnosis of right atrial aneurysm. Resection of the right atrial aneurysm was performed under total cardiopulmonary bypass. Besides a very thin muscular layer, histopathological evaluation of the aneurysm specimen revealed extensive eosinophilic infiltration at the epicardial side which, from place to place showed penetrations into the muscular layer. The screening tests performed for determination of the etiology of eosinophilia were indeterminate supporting the diagnosis of idiopathic right atrial aneurysm. In conclusion, although the reason for the eosinophilia could not be detected, it may have a part in the development of right atrial aneurysm that merits further investigation.

Anticoagulation in cardiomyopathy: unravelling the hidden threat and challenging the threat individually

Cardiomyopathy comprises a heterogeneous group of myocardial abnormalities, structural or functional in nature, in the absence of coronary artery disease and other abnormal loading conditions. These myocardial pathologies can result in premature death or disability from progressive heart failure, arrhythmia, stroke, or other embolic events. The European Cardiomyopathy Registry reports a high stroke risk in cardiomyopathy patients ranging from 2.1% to 4.5%, as well as high prevalence of atrial fibrillation ranging from 14.0% to 48.5%. There is a growing interest in evaluating the risk of thromboembolism depending on the type of cardiomyopathy, as well as if anticoagulation is indicated in patients with cardiomyopathy without atrial fibrillation. Data available do not unequivocally support anticoagulation therapy in all of these patients; the management of these patients remains challenging. Many published reports pertaining to the risk of thromboembolism and consecutive treatment strategies mainly focus on single cardiomyopathy subtype. We summarize essential pathophysiological knowledge and review current literature associated with thromboembolism in various cardiomyopathy subtypes, providing recommendations for the diagnostic evaluation as well as clinical management strategies in this field. Certain cardiomyopathy subtypes require anticoagulation independent of atrial fibrillation or CHA2 DS2 -VASc score. Despite the scarcity of evidence regarding the choice of anticoagulation regimen (vitamin K antagonist vs. non-vitamin K oral anticoagulants) in cardiomyopathy, it is discussed and reviewed in this article. Each patient should receive a tailored strategy based on thorough clinical evaluation, published evidence, and clinical experience, due to the current recommendations mostly developed on small-sample studies or empirical evidence. The future research priorities in this area are also addressed in this article.

Interesting features of Cardiac Magnetic Resonance in a Case of Hypereosinophilic Syndrome Secondary to Toxocariasis

Toxocariasis is a relatively common parasitic disease that can rarely affect the heart. Cardiac toxocariasis may lead to restrictive cardiomyopathy secondary to hypereosinophilia. CMR is a valuable diagnostic method in hypereosinophilic syndrome.

Hypereosinophilia with cerebral venous sinus thrombosis and intracerebral hemorrhage: A case report and review of the literature

BACKGROUND

Hypereosinophilia (HE) is defined as a peripheral blood eosinophil count of > 1.5 × 10⁹/L and may be associated with tissue damage. The clinical presentations of HE vary; however, myocardial fibrosis and thrombosis can threaten the lives of patients with sustained eosinophilia. Cerebral venous sinus thrombosis (CVST) in the setting of eosinophil-related diseases has seldom been reported. Here, we review the literature on HE with CVST to increase knowledge and encourage early diagnosis.

CASE SUMMARY

A previously healthy 41-year-old man was admitted to hospital with diarrhea and abdominal pain. He was treated with antibiotics for suspected acute colitis. Three days later, he experienced headache and vomiting. Brain computed tomography (CT) revealed thrombosis of the left jugular vein to the left transverse sinus vein. Platelet (PLT) count decreased to 60 × 10¹²/L, and absolute eosinophil count (AEC) increased to 2.41 × 10⁹/L. He was treated with low-molecular-weight heparin. PLT count progressively decreased to 14 × 10⁹/L, and we terminated anticoagulation and performed PLT transfusion. Six days after admission, he complained of a worsening headache. Brain CT revealed right temporal lobe and left centrum semiovale intracerebral hemorrhage, and AEC increased to 7.65 × 10⁹/L. We used prednisolone for HE. The level of consciousness decreased, so emergency hematoma removal and decompressive craniectomy for right cerebral hemorrhage were performed. The patient was alert 2 d after surgery. He was treated with anticoagulation again 2 wk after surgery. Corticosteroids were gradually tapered without any symptomatic recurrence or abnormal laboratory findings.

CONCLUSION

HE can induce CVST, and we need to focus on eosinophil counts in patients with CVST.

B-Cell-Depleting Therapy Improves Myocarditis in Seronegative Eosinophilic Granulomatosis with Polyangiitis

Cardiac involvement is a major mortality cause in eosinophilic granulomatosis with polyangiitis (EGPA), requiring novel therapeutics to spare the use of cyclophosphamide with known cardiotoxicity. Despite the observed efficacy of B-cell-depleting therapy in myocarditis of seropositive microscopic polyangiitis, it remains to be elucidated in seronegative EGPA. A retrospective study was performed in 21 hospitalized active patients aged 20 to 70 years with five-factor score 1 or 2, eosinophil counts 10,034 ± 6641/μL and vasculitis scores 27 ± 6. Overt myocarditis was identified in 10 cases, at disease onset in 6 and relapse in 4, with endomyocarditis in 4 and myopericarditis in 4. Five seronegative and one seropositive patient received rituximab with an induction regimen 375 mg/m² weekly × 4 for refractory or relapse disease, and the same regimen for annual maintenance therapy. All cases had lower eosinophil counts, improved cardiac dysfunction and clinical remission with a relapse-free follow-up, 48 ± 15 months after the induction treatment. One seronegative endomyocarditis patient had eosinophilia and disease relapse with asthma attack and worsening cardiac insufficiency 24 months after induction, achieving clinical remission under anti-IL-5 therapy. Our findings suggest the suppression of IL-5-mediated eosinophilia as an action mechanism of B-cell-depleting therapy in seronegative EGPA myocarditis.

Safety and efficacy of mepolizumab in hypereosinophilic syndrome: an open-label extension study

BACKGROUND

A double-blind, placebo-controlled Phase III study (200622) showed that mepolizumab reduces disease flares for patients with uncontrolled FIP1L1-PDGFRA-negative hypereosinophilic syndrome (HES) and ≥2 flares in the previous year.

OBJECTIVES

To further characterize the safety, clinical benefit, and pharmacodynamics of mepolizumab.

METHODS

Eligible patients from both treatment arms of the double-blind study could enter an open-label extension (OLE) study (205203; NCT03306043) to receive 4-weekly mepolizumab (300 mg subcutaneously) plus background therapy for 20 weeks. Primary endpoints were safety-based; other endpoints included flare rates and changes from baseline in mean daily oral corticosteroid (OCS) dose and blood eosinophil count (BEC).

RESULTS

Of 104 patients who completed the double-blind study, 98% (previous placebo n=52; previous mepolizumab n=50) enrolled in the OLE. Overall, 66 (65%) patients reported adverse events (AEs); 15 (15%) reported treatment-related AEs and 9 (9%) reported serious AEs. No events were fatal. The annualized flare rate (95% confidence interval) in the previous placebo and previous mepolizumab groups was 0.37 (0.16, 0.86) and 0.14 (0.04, 0.49) events/year, respectively. Of 72 patients receiving OCS during Weeks 0-4, 20 (28%; previous placebo, n=14; previous mepolizumab, n=6) achieved ≥50% reductions in mean daily dose during Weeks 16-20. At Week 20, BEC was reduced by 89% in patients previously receiving placebo and remained reduced for those previously receiving mepolizumab.

CONCLUSION

Extended mepolizumab treatment was associated with a positive benefit:risk profile. Continued control of disease flares and blood eosinophil counts, plus reductions in OCS use, were observed with mepolizumab in patients with FIP1L1-PDGFRA-negative HES.

Prominent Role of Type 2 Immunity in Skin Diseases-Beyond Atopic Dermatitis

Type 2 immunity, illustrated by T helper 2 lymphocytes (Th2) and downstream cytokines (IL-4, IL-13, IL-31) as well as group 2 innate lymphoid cells (ILC2), is important in host defense and wound healing.¹ The hallmark of type 2 inflammation is eosinophilia and/or high IgE counts and is best recognized in atopic diathesis. Persistent eosinophilia, such as seen in hypereosinophilic syndromes, leads to fibrosis and hence therapeutic Type 2 inhibition in fibrotic diseases is of high interest. Furthermore, as demonstrated in cutaneous T cell lymphoma, advanced disease is characterized by Th1 to Th2 switch allowing cancer progression and immunosuppression. Development of targeted monoclonal antibodies against IL-4Rα (eg, dupilumab) led to a paradigm shift for the treatment of atopic dermatitis (AD) and stimulated research to better understand the role of Type 2 inflammation in other skin conditions. In this review, we summarize up to date knowledge on the role of Type 2 inflammation in skin diseases other than AD and highlight whether the use of Type 2 targeted therapies has been documented or is being investigated in clinical trials. This manuscript reviews the role of Type 2 inflammation in dermatitis, neurodermatitis, IgE-mediated dermatoses (eg, bullous pemphigoid, chronic spontaneous urticaria), sclerodermoid conditions and skin neoplasms.

Normalization of left ventricular filling pressure after cardiac surgery for the Loeffler's endocarditis: a case report

Background

Loeffler endocarditis is a rare restrictive cardiomyopathy, characterized by hypereosinophilia and fibrous thickening of the endocardium causing progressive onset of heart failure and appearance of thrombi on the walls of the heart chambers.

Case summary

A 72-year-old man known for hypertension and dyslipidaemia consults for progressive dyspnoea up to New York Heart Association (NYHA) Classes 2–3 over 3 weeks. The biological balance sheet shows a high eosinophil level and an echocardiography shows a mild echodensity fixed to the left apex. After exclusion of a secondary cause of hypereosinophilia, diagnosis of endomyocardial fibrosis in the context of a hypereosinophilic syndrome (HES) is therefore retained. The patient’s clinical presentation with cardiac involvement leads us to start a treatment with corticosteroids. The patient is then regularly followed every 6 months with an initially stable course without complications. Two years later, he develops progressive signs of heart failure. Transthoracic echocardiography shows a left ventricular (LV) dilatation with a normal ejection fraction, but decreased volume due to a large echodense mass in the apex, and moderate aortic regurgitation caused by myocardial infiltration. In view of this rapid evolution, resection of the LV mass with concomitant aortic valve replacement is performed. Pathology confirms eosinophilic infiltration. The clinical course is very good with a patient who remains stable with dyspnoea NYHA Classes 1–2, and echocardiography at 1 year shows a normalization of LV filling pressure.

Discussion

HES represents a heterogeneous group of disorders characterized by overproduction of eosinophils. One of the major causes of mortality is associated cardiac involvement. Endocardial fibrosis and mural thrombosis are frequent cardiac findings. Echocardiography plays a crucial role in initial diagnosis of endomyocardial fibrosis, and for regular follow-up in order to adapt medical treatment and monitor haemodynamic evolution of the restrictive physiology and of valvular damage caused by the disease’s evolution. This case also shows that surgery can normalize filling pressure and allow a clear improvement on the clinical condition even at the terminal fibrotic state.

Hypereosinophilic syndrome: considerations for the cardiologist

Eosinophil-mediated endomyocardial damage is a well-known complication in patients with hypereosinophilic syndromes (HES). Although management and survival have improved significantly, some patients continue to develop severe cardiomyopathy as a direct consequence of uncontrolled hypereosinophilia. Cardiologists play a key role in early detection and treatment. At the early generally asymptomatic stage, related to subendocardial eosinophilic infiltrates, elevation of the biomarker of cardiac damage (serum troponin) and cardiac MRI are the best tools for diagnosis. As disease progresses, patients typically develop intracardiac mural thrombi and may experience variable degrees of heart failure due to valve damage and/or subendocardial fibrosis, all of which are more readily detectable with traditional echocardiographic investigation. New imaging modalities such as strain imaging and specific sequences in MRI offer the perspective of detecting subtle perturbations and distinguishing inflammatory versus fibrotic stages. Endomyocardial biopsy may help in difficult settings, namely, when blood eosinophilia is not prominent, but may be non-contributive due to sampling issues or eosinophil degranulation or replacement by fibrosis, and must always be performed after careful consideration of the risk:benefit ratio. Although treatment of the HES itself should be managed by clinicians with expertise in this rare disorder with the aim of lowering eosinophil counts to prevent and treat eosinophil-mediated organ damage and dysfunction, cardiologists play a key role in managing the associated cardiopathy. There are no consensual disease-specific guidelines for treating eosinophil-mediated thrombotic complications and cardiopathy, which should be managed according to classical international recommendations.

Irreversible coronary aneurysm presenting as acute coronary syndrome in a child with hypereosinophilic syndrome: a case report

Hypereosinophilic syndrome is defined as persistent eosinophilia in the blood for more than 6 months, without any identifiable cause and with end-organ involvement evidence. Cardiac manifestations of HES include heart failure due to restrictive cardiomyopathy, arrhythmia, intraventricular thrombosis, and coronary artery involvement occurs frequently. In rare instances, coronary ectasia, aneurysms, or dissection can occur and cause morbidity and mortality in these patients.A coronary aneurysm occurs rarely in adult patients with HES but to our knowledge, this is the first report of this association in a 14-year-old boy who was presented to us as coronary aneurysm due to hypereosinophilic syndrome.

Idiopathic Hypereosinophilic Syndrome with Multiple Organ Involvement

Idiopathic hypereosinophilic syndrome is a rare disease which is diagnosed after excluding other conditions. The syndrome is characterized by multiple organ involvement including the heart, nervous system, lungs, and gastrointestinal tract. The disease is suspected if there is peripheral blood eosinophilia and no clear etiology. The main treatment is corticosteroids. Patients who do not respond to corticosteroids can be treated with imatinib, immunomodulatory agents, myelosuppressive therapy, or mepolizumab. Alemtuzumab can be considered in severe cases that are unresponsive to other therapies. In this paper, we describe a case of idiopathic hypereosinophilic syndrome with mainly cardiac system involvement and left ventricular thrombus formation which was complicated by cerebral thromboemboli while on warfarin with international normalized ratio in the therapeutic range. Our patient responded well to steroids appreciated by improvement in clinical symptoms and decrease in eosinophil count.

Venous thrombosis and predictors of relapse in eosinophil-related diseases

Eosinophils have widespread procoagulant effects. Eosinophilic cardiovascular toxicity mostly consists of endomyocardial damage or eosinophilic vasculitis, while reported cases of venous thrombosis (VT) are scarce. We aimed to report on the clinical features and treatment outcomes of patients with unexplained VT and eosinophilia, and to identify predictors of relapse. This retrospective, multicenter, observational study included patients aged over 15 years with VT, concomitant blood eosinophilia ≥ 1G/L and without any other moderate-to-strong contributing factors for VT. Fifty-four patients were included. VT was the initial manifestation of eosinophil-related disease in 29 (54%) patients and included pulmonary embolism (52%), deep venous thrombosis (37%), hepatic (11%) and portal vein (9%) thromboses. The median [IQR] absolute eosinophil count at VT onset was 3.3G/L [1.6-7.4]. Underlying eosinophil-related diseases included FIP1L1-PDGFRA-associated chronic myeloid neoplasm (n = 4), Eosinophilic Granulomatosis with Polyangiitis (n = 9), lymphocytic (n = 1) and idiopathic (n = 29) variants of hypereosinophilic syndrome. After a median [IQR] follow-up of 24 [10-62] months, 7 (13%) patients had a recurrence of VT. In multivariate analysis, persistent eosinophilia was the sole variable associated with a shorter time to VT relapse (HR 7.48; CI95% [1.94-29.47]; p = 0.015). Long-term normalization of eosinophil count could prevent the recurrence of VT in a subset of patients with unexplained VT and eosinophilia ≥ 1G/L.

A Rare Case of Löffler "Pancarditis" Associated with Hypereosinophilic Syndrome

A 53-year-old woman was admitted to another hospital because of a 2-month history of repeated chest pain and breathlessness. Laboratory examinations demonstrated the presence of hypereosinophilia (absolute count of 6,500/μL). An endomyocardial biopsy confirmed eosinophilic infiltration with myocardial destruction. On cardiac magnetic resonance imaging, late gadolinium enhancement was clearly observed along the visceral pericardium as well as on the endocardial layer. Based on the multimodal imaging and histopathological findings, the final diagnosis of "Löffler pancarditis" was made. After the introduction of steroid therapy, the left ventricular contractile function significantly recovered. Furthermore, the late gadolinium enhancement of the visceral pericardium had attenuated.

Contrast-Enhanced Echocardiography Imaging With a Noncontrast MRI Technique Used in a Patient With Chronic Kidney Disease to Diagnose Loeffler Endocarditis

Loeffler endocarditis is rare and can initially be a clinically silent cardiac disorder. Given its natural history with evolving stages and its vague initial cardiac presentation, it is important to keep this as a differential diagnosis. Without treatment, this disorder is progressive and may lead to a possible restrictive cardiomyopathy-related heart failure. Here, a rare case who presented with nonspecific chest pain is reported, which was recognized early by a routine noninvasive transthoracic echocardiography (TTE) imaging study. This was followed by the addition of contrast enhancement techniques, which made it possible to solidify the diagnosis of the mass to a right ventricular thrombus (possibly secondary to the hypereosinophilia syndrome), with isolated right ventricular involvement. Magnetic resonance imaging (MRI) of the heart, without contrast, was performed to further analyze the anatomic location of this entity. A high index of suspicion for Loeffler endocarditis helped identify this condition.

Hypereosinophilia and Löffler's Endocarditis: A Systematic Review

Löffler endocarditis is an uncommon, but known complication of hypereosinophilic syndrome (HES). It is a relatively rare entity, and remains poorly understood. To this point in time, the compendium of knowledge about this disease consists of various case reports, prospective studies and review articles. We aim to present a scoping study about this disease. Our goals are to identify the characteristic features found in case reports to identify characteristic features found in patients with Löffler endocarditis as a result of hypereosinophilic syndrome. An analysis of the 26 case reports showed a mean age of 41.6 years with a standard deviation of 17.1 years. Dyspnea was the most common presenting complaint (64%) followed by fatigue (23%), cough (19%), fever (19%), orthopnea/paroxysmal nocturnal dyspnea (19%), stroke related symptoms (15%), chest pain (15%) and lower extremity edema (15%). The most common cardiac structure affected was the mitral valve (65%), followed by the tricuspid valve (42%), left ventricle (23%), with 35% of cases having involvement of two valves. The most common therapeutic modality was immunosuppression (85%), followed by anticoagulation (73%) and mitral valve replacement (23%). Death was reported in 19% of the cases. Löffler's endocarditis continues to be associated with high morbidity and mortality. Further research must aim to develop guidelines for management of this uncommon manifestation of hypereosinophilic syndrome.

Idiopathic hypereosinophilic syndrome with intracardiac atypical linear-shaped and floating thrombus presenting as embolic cerebral infarction

Knowledge of the multi-organ involvement in hypereosinophilic syndrome (HES) is important for the diagnosis and care of patients with this condition, even in cases with atypical presentation. This report aims to describe cerebral embolic infarction and intracardiac atypical linear-shaped thrombus in a patient with idiopathic HES and to discuss the approach of appropriate diagnosis and timely interventional management. A 55-year-old man presented with general weakness, including left-sided weakness, mild cognitive dysfunction, and mild exertional dyspnea for about 2 weeks. Initial magnetic resonance imaging for evaluating the brain showed multifocal acute to subacute infarction of both cerebral hemispheres and both cerebellums. Laboratory findings revealed leukocytosis (25,620 cells/mm³) and eosinophilia (54.9%). To evaluate the intracardiac embolic source, the patient underwent echocardiography, and a 1.5 cm linear thread-like and mobile mass was detected. Consequently, the patient was diagnosed with idiopathic HES. After bone marrow biopsy, corticosteroid and hydroxyurea were administered to control the eosinophilia. This case indicates that HES can present as a floating intracardiac atypical linear-shaped thrombus attached to the left ventricle. After appropriate diagnostic approaches, proper treatment could be given for the patient. <Learning objective: Idiopathic hypereosinophilic syndrome (HES) is a disorder characterized by persistent eosinophilia with heterogeneous clinical manifestations. Knowledge of the multi-organ involvement in HES is important for the diagnosis and care of patients with this condition, even in cases with atypical shaped thrombus as clinical presentation. Close monitoring combined with early treatment and diagnosis may help reduce mortality in HES patients.>.

Multiple Biological Aspects of Eosinophils in Host Defense, Eosinophil-Associated Diseases, Immunoregulation, and Homeostasis: Is Their Role Beneficial, Detrimental, Regulator, or Bystander?

Eosinophils are innate immune leukocytes and play important roles as terminal effector cells owing to their mediators, such as tissue-destructive cationic proteins, cytokines, chemokines, and lipid mediators. Historically, they are not only considered an important player in host defense against parasitic, viral, fungal, and bacterial infections but also implicated in the pathogenesis of eosinophil-associated diseases, such as allergic rhinitis, asthma, eosinophilic chronic rhinosinusitis, esophagitis, atopic dermatitis, myopathies, and hypereosinophilic syndrome. Moreover, recent studies have shown that eosinophils have an immune regulatory and homeostatic function. Interestingly, there is emerging evidence that eosinophils are accumulated through adoptive T-helper 2 (Th2) and innate Th2 responses, mechanisms of the classical allergen-specific immunoglobulin E (IgE)-mediated response, and group 2 innate lymphoid cell-derived interleukin-5, respectively. Furthermore, in agreement with current concepts of eosinophil subtypes, it has been shown that resident and phenotypically distinct eosinophils, i.e., resident and recruited inflammatory eosinophils, exist in inflamed sites, and each has different functions. Thus, the classical and novel studies suggest that eosinophils have multiple functions, and their roles may be altered by the environment. In this article, we review multiple biological aspects of eosinophils (novel and classical roles), including their beneficial and detrimental effects, immunoregulation, and homeostatic function.