Clinical spectrum and endomyocardial biopsy findings in eosinophilic heart disease

Diagnosis and treatment of eosinophilic myocarditis

Eosinophilic myocarditis is a type of inflammatory cardiomyopathy characterized by eosinophilic infiltration into myocardial tissue. The accurate myocarditis incidence rate is difficult to determine because of the clinical limitations of an endomyocardial biopsy. The primary pathogenesis of eosinophilic myocarditis is the release of related substances by eosinophils, leading to cell membrane damage and cell destruction. However, evidence suggests that specific genes play a role in myocarditis development.As CMR imaging availability increases, the diagnosis rate of eosinophilic myocarditis will increase. The diagnosis of myocarditis mainly depends on an endocardial biopsy. Glucocorticoids can relieve patients' symptoms, but the early use of steroids may prevent intermediate disease stage development (i.e., thrombonecrosis and fibrosis with wall thrombosis). Anticoagulant therapy may also affect disease development. In addition to routine follow-up, a regular myocardial biopsy should be considered for discharged patients, if possible.

Allergy and the Heart: Eosinophilic Myocarditis With Biventricular Thrombi

A 40-year-old woman with history of atopy and peripheral eosinophilia presented with clinical signs of heart failure. Echocardiography revealed a restrictive cardiomyopathy with biventricular thrombi. Hypereosinophilic syndrome resulting in eosinophilic myocarditis (Loeffler’s syndrome) was diagnosed. This case highlights the workup, diagnosis, and management of hypereosinophilic syndrome with eosinophilic myocarditis. (Level of Difficulty: Advanced.)

Loeffler's Endocarditis and Hypereosinophilic Syndrome

Loeffler's endocarditis and hypereosinophilic syndromes are a unique group of infiltrative disorders characterized by hypereosinophilia, inflammatory thrombotic, and ultimately, fibrotic involvement of the heart leading to multiple complications including valve involvement, thromboembolic phenomena, heart failure. Clinical recognition, comprehensive laboratory and multimodality imaging diagnostic workup, and early initiation of treatment have been shown to slow down the progression and promote remission. This review addresses a detailed analysis of Loeffler's endocarditis and hypereosinophilic syndromes.

Pathogenesis and classification of eosinophil disorders: a review of recent developments in the field

Eosinophils and their products play an essential role in the pathogenesis of various reactive and neoplastic disorders. Depending on the underlying disease, molecular defect and involved cytokines, hypereosinophilia may develop and may lead to organ damage. In other patients, persistent eosinophilia is accompanied by typical clinical findings, but the causative role and impact of eosinophilia remain uncertain. For patients with eosinophil-mediated organ pathology, early therapeutic intervention with agents reducing eosinophil counts can be effective in limiting or preventing irreversible organ damage. Therefore, it is important to approach eosinophil disorders and related syndromes early by using established criteria, to perform all appropriate staging investigations, and to search for molecular targets of therapy. In this article, we review current concepts in the pathogenesis and evolution of eosinophilia and eosinophil-related organ damage in neoplastic and non-neoplastic conditions. In addition, we discuss classifications of eosinophil disorders and related syndromes as well as diagnostic algorithms and standard treatment for various eosinophil-related disorders.

Eosinophilic myocarditis mimicking acute coronary syndrome secondary to idiopathic hypereosinophilic syndrome: a case report

Introduction

Eosinophilic myocarditis is a rare form of myocarditis. It is characterized pathologically by diffuse or focal myocardial inflammation with eosinophilic infiltration, often in association with peripheral blood eosinophilia. We report a case of eosinophilic myocarditis secondary to hypereosinophilic syndrome.

Case presentation

A 74-year-old Caucasian woman with a history of asthma, paroxysmal atrial fibrillation, stroke and coronary artery disease presented to the emergency department of our hospital with chest pain. Evaluations revealed that she had peripheral blood eosinophilia and elevated cardiac enzymes. Electrocardiographic findings were nonspecific. Her electrocardiographic finding and elevated cardiac enzymes pointed to a non-ST-elevated myocardial infarction. Echocardiogram showed a severe decrease in the left ventricular systolic function. Coronary angiogram showed nonobstructive coronary artery disease. She then underwent cardiac magnetic resonance imaging, which showed neither infiltrative myocardial diseases nor any evidence of infarction. This was followed by an endomyocardial biopsy which was consistent with eosinophilic myocarditis. Hematologic workup regarding her eosinophilia was consistent with hypereosinophilic syndrome. After being started on steroid therapy, her peripheral eosinophilia resolved and her symptoms improved. Her left ventricular ejection fraction, however, did not improve.

Conclusion

Eosinophilic myocarditis can present like an acute myocardial infarction and should be considered in the differential diagnosis of acute coronary syndrome in patients with a history of allergy, asthma or acute reduction of the left ventricular function with or without peripheral eosinophilia.

Chest pain in a 12-year-old boy: when is it a harbinger of poor outcome?

Chest pain is usually a benign presentation in children who present to emergency departments (ED) or primary care centers. Unlike adults, where chest pain is commonly due to cardiac causes, in children the cause is more likely secondary to non-cardiac causes. Here we present a case of a child known to have hyper-eosinophilic syndrome (HES) who presented with sudden onset of chest pain and had a rapidly progressive and fatal outcome in the ED. We discuss the ED approach to the child with chest pain and review acute myocardial infarction (AMI) in children.

Idiopathic eosinophilic endomyocarditis in the absence of peripheral eosinophilia

In this case report we present two patients with unusual manifestations of eosinophilic endomyocarditis: A 69-year-old patient with a history of heart failure and ventricular fibrillation and a 16-year-old woman with ventricular fibrillation and an ECG indicating acute myocardial infarction had both normal blood eosinophil counts at the onset of symptoms. The absence of hypereosinophilia, therefore, does not exclude the presence of eosinophilic organ infiltration. Endomyocardial biopsy may be the only diagnostic procedure to identify necrotic eosinophilic endomyocarditis in patients with unexplained heart failure or ventricular fibrillation.

Diastolic heart failure. Constrictive, restrictive, and pericardial

Clinical heart failure with normal systolic function is suggestive of diastolic dysfunction. This can result from myocardial or pericardial disorders. Myocardial disorders are a broad range of pathologies leading to restrictive physiology. Amyloidosis is a prototype of restrictive cardiomyopathy leading to diastolic dysfunction. Pericardial disorders leading to diastolic heart failure are usually in the form of constrictive physiology. Differentiation between restrictive and constrictive pathologies is often difficult and require careful attention to hemodynamic and Doppler echocardiographic features.

Eosinophilic myocarditis complicated by acute myocardial infarction--a case report

The authors report a patient with eosinophilic myocarditis who developed severe chest pain with marked elevation of the ST segment on the electrocardiogram, which led them to suspect the presence of acute myocardial infarction. Emergency coronary angiography showed numerous occlusions and stenoses at the distal right and left coronary arteries, especially affecting the latter, owing probably to thrombus. The angiographic findings in this case demonstrate the formation and obstruction of thrombus in the small coronary arteries in a patient in the acute necrotic stage of eosinophilic myocarditis, believed to be the first such case reported.

Hypereosinophilic syndrome

The hypereosinophilic syndrome is a multisystem syndrome characterized by peripheral blood eosinophilia and eosinophil infiltration of bone marrow, heart, and other organs. The syndrome is associated with cardiac, hematological, pulmonary, neurological, and cutaneous involvement and, if untreated, has a high fatality rate. Criteria for the diagnosis of hypereosinophilic syndrome include (1) peripheral blood eosinophilia with eosinophil counts greater than 1,500/microL for at least 6 months; (2) no evidence of parasitic, allergic, or other known causes of eosinophilia; and (3) presumptive signs and symptoms of multiple organ involvement. Cutaneous manifestations occur commonly but are not diagnostic either clinically or histologically, although the presence of angioedema is a favorable prognostic sign. Because eosinophils are thought to mediate important pathogenic effects, treatment is aimed at controlling peripheral blood eosinophilia.

[Segmental myocarditis in Churg-Strauss syndrome. Review of the literature apropos of a case]

We describe a 25-year old man in whom segmental myocarditis and pericarditis was diagnosed using two-dimensional echocardiography. Churg-Strauss syndrome was suspected in the presence of asthma and evidence of hypereosinophilia. Early therapy with oral prednisone led to resolution of pericarditis but septal hypokinesia was still present after 4 years. The pathophysiology of segmental myocarditis in the Churg Strauss syndrome is discussed.

Histopathologic and ultrastructural observations of acute and convalescent myocarditis: a serial endomyocardial biopsy study

Serial endomyocardial biopsy findings were analyzed in ten cases with acute myocarditis of possible viral origin. The histopathologic findings were analyzed at the acute (0-10 days after the onset), subacute (11-21 days), and convalescent stages (22-167 days). The incidence and severity of various cardiac myocyte and interstitial changes were compared at each stage of the disease. The time-course changes of the histopathologic findings in acute myocarditis were as follows. At the acute stage, we observed: interstitial cell infiltration composed of fibroblasts, macrophages, and lymphocytes, fragmentation of the muscle bundles, myocytolytic changes, swelling and scarcity of the cytoplasm and swelling of nuclei, variation in size of the myocytes, disarrangement of the muscle bundles, interstitial edema, increased glycogen deposition in the myocytes, abnormal branching of the myocytes, and interstitial fibrosis. At the convalescent stage, most of the above findings could still be seen except for myocytolytic changes, swelling of myocytes, and interstitial edema. At the subacute and convalescent stages, an increase in abnormal branching and in double nuclei in the myocytes and nuclear degeneration became observable. A further control study comparing the changes at the convalescent stage of myocarditis and the myocardial changes in cases with chronic right ventricular overload in 58 cases revealed that in the former fragmentation of the muscle bundles, abnormal branching, size variation, glycogen deposition, and large mononuclear cell infiltrations were significantly more frequent. Ultrastructural observation of the myocytes revealed that they have a great potentiality for regeneration; myocytes showing severe myocytolytic changes may recover to regain an architecture of almost normal appearance.