Congestive cardiomyopathy and endobronchial granulomas as manifestations of Churg-Strauss syndrome

Cardiovascular Magnetic Resonance Imaging in Myocardial Disease

Cardiovascular magnetic resonance (CMR) is the central non-invasive imaging investigation for the evaluation of myocardial disease. It is the well-established gold standard for measuring cardiac chamber volumes, systolic function, and left ventricular mass, and it brings unique information for therapeutic decisions. In addition, its tissue characterization capability, through T1, T2, and T2* mapping, as well as early and late gadolinium enhancement (LGE) sequences, allows to differentiate in many cases among ischemic, inflammatory, and infiltrative heart disease and permits the quantification of myocardial fibrosis, providing valuable diagnostic and prognostic information. This review aims to highlight the main CMR features of different cardiomyopathies.

Churg-Strauss syndrome and persistent heart failure: active disease or damage?

Churg-Strauss syndrome (CSS) is a rare small-vessel vasculitis typically associated with adult-onset asthma, peripheral and tissue hypereosinophilia, migratory pulmonary infiltrates, upper respiratory tract symptoms, and clinical evidence of systemic vasculitis. Cardiac involvement is a well-recognized complication with an estimated prevalence of 60%. Heart disease is associated with poor prognosis, accounting for almost 50% mortality in CSS. We present a case of a 48-year-old woman with CSS complicated by congestive heart failure with left ventricular ejection fraction of 25%, who was initially treated with long course of high-dose steroids without any clinical or echocardiographic improvement. She was referred to our hospital 1 year later and was initiated with cyclophosphamide 2 mg/kg per day and prednisone 60 mg/d followed by slow taper. Subsequently, the patient had remarkable improvement. Patient was then transitioned to azathioprine for 1.5 years with sustained disease remission. It may be difficult to determine myocardial disease activity status versus tissue damage in CSS with prolonged duration of heart failure symptoms. This is the first case report demonstrating that CSS cardiac disease may remain active despite 1 year of corticosteroid therapy, and significant improvement or remission can still be achieved by administering more aggressive cytotoxic immunosuppressive therapy.

Tracheobronchial lesions in eosinophilic pneumonia

BACKGROUND

Eosinophilic pneumonia (EP) is characterized by eosinophil infiltration in the lung parenchyma. However, tracheobronchial lesions associated with the disease have been poorly described. To clarify the frequency and characteristics of cases with tracheobronchial lesions in EP, we performed a retrospective review of EP patients.

METHODS

We included 36 EP cases seen from January 2004 to December 2007 at the Kinki-Chuo Chest Medical Center. The incidence of tracheobronchial nodules and associated clinical features were analyzed.

RESULTS

Of these 36 patients, 29 had chronic eosinophilic pneumonia (CEP); 1, acute EP; 3, drug-induced EP; 2, allergic bronchopulmonary aspergillosis; and 1, parasite-related EP. Only 2 of the 29 CEP cases had tracheobronchial lesions. For both of these cases, bronchoscopy revealed multiple whitish nodules on the tracheobronchial mucosa. The associated histopathological findings revealed squamous metaplasia and eosinophil infiltration in the subepithelial region. In both cases, the nodules disappeared after steroid therapy. The prevalence of tracheobronchial lesions was 6.9% in CEP patients and 5.6% in EP patients overall. EP patients were divided into 3 groups: CEP with nodules (n=2), CEP without nodules (n=27), and other EP (n=7). We found that the CEP with nodules group showed a relatively higher incidence of respiratory symptoms, higher white blood cell (WBC) count, and higher levels of peripheral and bronchoalveolar eosinophilia than the other groups.

CONCLUSIONS

Tracheobronchial nodules represent rare observations within the EP population, which are likely to reflect a severe disease condition.

CMR in Heart Failure

Heart Failure (HF) is a common syndrome with multiple causes. Cardiovascular magnetic resonance (CMR) is a medical imaging technique with significant advantages, allowing the understanding of aetiology and pathophysiology of HF in the individual patient, permitting specific therapy to be administered and predicting prognosis. This paper discusses the diverse role of CMR in HF.

Multiple tracheobronchial mucosal lesions in two cases of Churg-Strauss syndrome

Churg-Strauss syndrome (CSS) is characterized by hypereosinophilia and a systemic necrotizing vasculitis seen almost exclusively in patients with asthma. The most common pathological findings in the chest in CSS are eosinophilic pneumonia, necrotizing vasculitis and granulomatous inflammation (extravascular granuloma). However, tracheobronchial mucosal lesions have rarely been reported in CSS. The authors report two patients with CSS who had multiple tracheobronchial mucosal lesions that were found by fibreoptic bronchoscopy. They were tiny nodular lesions and necrotizing bronchial inflammation with many eosinophils was observed upon pathological examination. The authors concluded that tracheobronchial mucosal lesions may be one of the manifestations of vasculitis seen in CSS.

Cardiac involvement in the Churg-Strauss syndrome

Churg-Strauss syndrome (CSS) is a rare systemic disease characterized by necrotizing vasculitis and peripheral eosinophilia. Cardiac involvement is considered common and is given a high rank among the causes of morbidity and mortality. The aim of this study was an update on the cardiac manifestations of this syndrome using a noninvasive approach. Sixteen patients with CSS were compared with a gender- and age-matched group of 20 healthy subjects. All patients but 1 were receiving treatment (steroids and/or immunosuppressive drugs). According to the Birmingham vasculitis activity score, 12 patients were in an active phase, and 4 were in drug-induced remission. All subjects underwent M-B-mode echocardiography and Doppler tissue echocardiography. Heart failure, life-threatening arrhythmias, and other prominent manifestations of heart disease were not observed. No differences were found in left ventricular diameter, volume, mass, or ejection fraction. The 2 groups did not differ in right ventricular diameter and pulmonary pressure. Few and nonspecific changes were detected by 2-dimensional echocardiography, including subclinical pericardial effusion and mitral regurgitation, in fewer than half the subjects. Subjects with CSS showed an impairment of ventricular relaxation. Changes were more prominent in the right ventricle. The peak velocity (PV) of early diastolic tricuspid inflow (E) was about 8% less than in controls, and the velocity of late diastolic inflow (A) was 35% greater. The E/A(PV) ratio was, on average, 33% less. In the left ventricle, E(PV) was 11% less and A(PV) 11% greater. The E/A ratio was decreased by 22%. Doppler analysis of tissue kinetics confirmed these indications. In the right ventricle, E(PV) was decreased by 10% and A(PV) was increased by 20% in the patient group. The E/A(PV) ratio was decreased by 29%. In the left ventricle, in which different sites were sampled, the average changes were -15%, +1%, and -23%, respectively. In the left ventricle, the velocity of systolic contraction was also decreased by 12%. Because of the small group size, only some of these differences were statistically significant. In conclusion, these moderate changes, devoid of clinical correlates, contrast with early reports emphasizing cardiac morbidity and poor prognosis in this syndrome.

Endomyocardial fibrosis in Churg–Strauss syndrome assessed by cardiac magnetic resonance imaging

Cardiac involvement frequently occurs in hypereosinophilic syndrome. The endocardium seems to be most susceptible to disturbances deriving from eosinophilia as seen in Loeffler's endocarditis. Hypereosinophilia and cardiac involvement are also seen in Churg-Strauss syndrome. The present report deals with a patient with Churg-Strauss syndrome who exhibited marked endomyocardial fibrosis that was visualized by cardiac magnetic resonance imaging. Loeffler's endocarditis is the classical endocardial manifestation of hypereosinophilic syndrome. Similarities between Loeffler and Churg-Strauss syndromes had been described previously. Potentially, endocardial involvement is more common even in Churg-Strauss syndrome than expected so far. The significance of these findings remains to be shown.

Churg-Strauss syndrome complicated by eosinophilic endomyocarditis

A 34-year-old woman with asthma had increasing dyspnea on exertion for 9 months and new-onset mononeuritis multiplex. An examination demonstrated sinus tachycardia, elevated jugular venous pressure, and a tender nonpulsatile liver. The leukocyte count was 15.8 x 10(9)/L, with 23% eosinophils. Echocardiography revealed a laminated thrombus obliterating much of the right ventricular cavity, with encasement of the tricuspid valve. Ultrafast computed tomography showed no evidence of pulmonary emboli. Biopsy specimens of skin nodules revealed extravascular palisading granulomas. The thrombus was refractory to corticosteroids, and right ventricular thrombectomy was performed. To our knowledge, this is the third reported case of Churg-Strauss syndrome with thrombotic complications from coexistent eosinophilic endomyocarditis. In an asthmatic patient with chronic dyspnea, eosinophilic tissue infiltration, and neuropathy, Churg-Strauss syndrome should be considered; evaluation for cardiac involvement may be warranted.