A case of sudden cardiac death due to eosinophilic coronary periarteritis: possible significance of coexisting atherosclerosis and eosinophilic inflammation of the esophagus

An autopsy case of sudden unexpected death with loxoprofen sodium-induced allergic eosinophilic coronary periarteritis

Although the cause of eosinophilic coronary periarteritis (ECPA) remains unclear, an allergic background is present in fewer patients than expected. A 50-year-old man with no history of allergy or symptoms suggestive of cardiac or respiratory disorders suddenly died shortly after oral administration of loxoprofen sodium. Autopsy showed eosinophilic coronary periarteritis in three main branches of the coronary arteries, characterized by eosinophil-predominant inflammation without fibrinoid necrosis or granulomatous change in the adventitia and its surroundings of the three main branches of the coronary arteries, in addition to the localized sign of bronchial asthma in the lung. Immunohistochemical examination showed that many mast cells positive for human mast cell tryptase were evident in the perivascular tissue containing peripheral nerve trunks. Whereas the blood concentration of loxoprofen sodium was within the therapeutic range, significant elevation of the serum histamine and tryptase levels was found. The present case suggests that eosinophilic coronary periarteritis may be caused by a type I allergic reaction in some patients and that loxoprofen sodium can trigger a life-threatening type I allergic reaction, including eosinophilic coronary periarteritis, leading to sudden unexpected death.

Clinicopathological complexity in the application of the universal definition of myocardial infarction

A universal definition of myocardial infarction (UDMI) has been established, periodically updated, and refined over the past twenty years. The primary purpose of the UDMI is to bring uniformity and accuracy to clinical diagnosis. Herein, a review and analysis of the UDMI is presented with emphasis on clinicopathological correlation. Determination of the presence of myocardial injury is based on the detection of abnormal serum cardiac biomarkers, particularly cardiac troponin (cTn), and in the current fourth iteration of the UDMI, high sensitivity (hs)-cTn. Differentiation of myocardial infarction from other causes of myocardial injury requires the documentation of clinical evidence of myocardial ischemia. In this review, difficulties in applying the UDMI in actual practice are discussed, based on the experience and perspective of those of us who face these problems as part of our own practice of pathology. The complexity in application of the UDMI is highlighted by the presentation of five illustrative cases involving the differential diagnosis of myocardial injury and myocardial infarction due to atherothrombotic and nonatherothrombotic coronary artery disease. The cases include myocardial infarction due to severe coronary atherosclerosis, supply-demand mismatch, coronary artery dissection associated with an eosinophilic coronary periarteritis, and coronary thromboembolism, and a case with a differential diagnosis of myocarditis and myocardial infarction. These cases illustrate how pathological findings can contribute to more accurate application of the UDMI and how, when critically applied, the UDMI can be used to better characterize myocardial infarcts in clinical practice.

Systemic inflammatory activation in patients with acute coronary syndrome secondary to nonatherosclerotic spontaneous coronary artery dissection

OBJECTIVE

Pathological studies have suggested that local inflammation, particularly eosinophilic infiltration of the adventitia, could be related to nonatherosclerotic spontaneous coronary artery dissection (NA-SCAD). However, the role of systemic inflammation in the pathogenesis of NA-SCAD remains unknown. Our aim was to investigate systemic inflammatory activation in patients with an acute coronary syndrome (ACS) secondary to NA-SCAD.

METHODS

The institutional electronic medical database was reviewed, and 22 patients with NA-SCAD-ACS were identified after the review. Furthermore, 30 random patients with CAD-ACS and 30 random subjects without any history of CAD or ACS with demographic and clinical characteristics similar to those of NA-SCAD-ACS patients were identified from the institutional database to be included in the study.

RESULTS

Patients with NA-SCAD-ACS and those with CAD-ACS both had higher white blood cell and neutrophil counts than controls. Neutrophil-lymphocyte ratio (NLR) and C-reactive protein (CRP) levels were only significantly higher in the NA-SCAD-ACS group [2.01 (1.54-6.17) for NLR and 0.70 (0.13-2.70) for CRP] than in the controls [1.55 (1.27-2.13), p=0.03 for NLR and 0.15 (0.10-0.43), p=0.049 for CRP]; however, there were no differences between the NA-SCAD-ACS and CAD-ACS groups [1.91 (1.41-2.78) for NLR and 0.41 (0.09-1.10) for CRP, p>0.05 for both comparisons] regarding all tested parameters.

CONCLUSION

The degree of inflammatory activation in NA-SCAD-ACS patients was similar to, or even greater than, that in CAD-ACS patients; thus, suggesting a role of inflammation in the pathophysiology of NA-SCAD-ACS.

Anatomopathological changes of the cardiac conduction system in sudden cardiac death, particularly in infants: advances over the last 25 years

Sudden cardiac death (SCD) is defined as the unexpected death without an obvious noncardiac cause that occurs within 1 h of witnessed symptom onset (established SCD) or within 24 h of unwitnessed symptom onset (probable SCD). In the United States, its incidence is 69/100,000 per year. Dysfunctions of the cardiac conduction and autonomic nervous systems are known to contribute to SCD pathogenesis, even if most clinicians and cardiovascular pathologists lack experience with detailed examination of the cardiac conduction system and fail to recognize lesions that are crucial to explain the SCD itself. In this review, we sought to describe the advances over the last 25 years in the study of the anatomopathological changes of the conducting tissue, in SCD, in mature hearts and particularly in sudden infant death syndrome (SIDS) and sudden intrauterine unexpected death syndrome (SIUDS), through the articles published in our journal Cardiovascular Pathology (CVP). We carried out an extensive Medline search to retrieve and review all articles published in CVP in which the sudden unexpected death of one or more subjects believed healthy was reported, especially if associated with lesions of the conducting tissue in settings that revealed no other explained causes of death, particularly in infants and fetuses. The cardiac conduction findings of resorptive degeneration, His bundle dispersion, Mahaim fibers, cartilaginous meta-hyperplasia, persistent fetal dispersion, left-sided His bundle, septation of the bifurcation, atrioventricular node dispersion, sinus node hypoplasia, Zahn node, His bundle hypoplasia, atrioventricular node, and His bundle dualism were similarly detected in SIDS and SIUDS victims.