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Mezzetti E, Costantino A, Leoni M, Pieretti R, Di Paolo M, Frati P, Maiese A, Fineschi V. Autoimmune Heart Disease: A Comprehensive Summary for Forensic Practice. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1364. [PMID: 37629654 PMCID: PMC10456745 DOI: 10.3390/medicina59081364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/05/2023] [Accepted: 07/20/2023] [Indexed: 08/27/2023]
Abstract
Autoimmune heart disease is a non-random condition characterised by immune system-mediated aggression against cardiac tissue. Cardiac changes often exhibit nonspecific features and, if unrecognised, can result in fatal outcomes even among seemingly healthy young individuals. In the absence of reliable medical history, the primary challenge lies in differentiating between the various cardiopathies. Numerous immunohistochemical and genetic studies have endeavoured to characterise distinct types of cardiopathies, facilitating their differentiation during autopsy examinations. However, the presence of a standardised protocol that forensic pathologists can employ to guide their investigations would be beneficial. Hence, this summary aims to present the spectrum of autoimmune cardiopathies, including emerging insights such as SARS-CoV-2-induced cardiopathies, and proposes the utilisation of practical tools, such as blood markers, to aid forensic pathologists in their routine practice.
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Affiliation(s)
- Eleonora Mezzetti
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Andrea Costantino
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Matteo Leoni
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Rebecca Pieretti
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Marco Di Paolo
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopedical Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (P.F.); (V.F.)
| | - Aniello Maiese
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopedical Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (P.F.); (V.F.)
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Bond M, Fagni F, Moretti M, Bello F, Egan A, Vaglio A, Emmi G, Dejaco C. At the Heart of Eosinophilic Granulomatosis with Polyangiitis: into Cardiac and Vascular Involvement. Curr Rheumatol Rep 2022; 24:337-351. [PMID: 36194339 DOI: 10.1007/s11926-022-01087-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/23/2022] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Milena Bond
- Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, Italy
| | - Filippo Fagni
- Department of Internal Medicine 3 - Rheumatology and Immunology, Friedrich-Alexander University Erlangen-Nuremberg and Universitätsklinikum Erlangen, Erlangen, Germany
| | - Michele Moretti
- Department of Cardiology - Azienda Provinciale Per I Servizi Sanitari Di Trento, Trento, Italy
| | - Federica Bello
- Department of Experimental and Clinical Medicine, University of Firenze, and Internal Interdisciplinary Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Allyson Egan
- Vasculitis & Lupus Unit, Department of Medicine, Addenbrookes Hospital, Cambridge, UK
| | - Augusto Vaglio
- Nephrology and Dialysis Unit, Meyer Children's Hospital, Florence, Italy.,Department of Biomedical, Experimental and Clinical Sciences "Mario Serio", University of Firenze, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, and Internal Interdisciplinary Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, Italy. .,Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria.
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3
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Goldar G, Garraud C, Sifuentes AA, Wassif H, Jain V, Klein AL. Autoimmune Pericarditis: Multimodality Imaging. Curr Cardiol Rep 2022; 24:1633-1645. [PMID: 36219367 DOI: 10.1007/s11886-022-01785-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF THE REVIEW The purpose of this review is to understand the underlying mechanism that leads to pericarditis in systemic autoimmune and autoinflammatory diseases. The underlying mechanism plays a vital role in the appropriate management of patients. In addition, we will review the current landscape of available cardiac imaging modalities with emphasis on pericardial conditions as well as proposed treatment and management tailored toward pericardial autoimmune and autoinflammatory processes. RECENT FINDINGS Approximately 22% of all cases of pericarditis with a known etiology are caused by systemic autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, and vasculitis. In recent years, there have been advancements of imaging modalities including cardiac MRI, cardiac CT scan, and PET scan and their respective nuances in regard to contrast use, technique, and views which clinicians may utilize to better understand the extent of a patient's pericardial pathology and the trajectory of his or her disease process. In this review, we will discuss systemic autoimmune and autoinflammatory diseases that involve the pericardium. We will also review different imaging modalities that are currently used to further characterize such conditions. Having a deeper understanding of such techniques will improve patient outcomes by helping clinicians tailor treatment plans according to the unique underlying condition.
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Affiliation(s)
- Ghazaleh Goldar
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA.
| | - Cassandra Garraud
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Aaron A Sifuentes
- University of Michigan Department of Internal Medicine, Ann Arbor, MI, USA
| | - Heba Wassif
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Vardhmaan Jain
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J1-5, Cleveland, OH, 44195, USA
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4
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Jain V, Chhabra G, Chetrit M, Bansal A, Berglund F, Montanè B, Furqaan MM, Bachour SP, Kontzias A, Villa-Forte A, Aronow WS, Imazio M, Cremer PC, Klein AL. Role of non-invasive multimodality imaging in autoimmune pericarditis. Eur Heart J Cardiovasc Imaging 2021; 22:1228-1240. [PMID: 34333596 DOI: 10.1093/ehjci/jeab131] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 06/17/2021] [Indexed: 01/24/2023] Open
Abstract
Systemic autoimmune diseases are an important cause of pericardial involvement and contribute to up to ∼22% cases of pericarditis with a known aetiology. The underlying mechanism for pericardial involvement varies with each systemic disease and leads to a poor understanding of its management. Multimodality imaging establishes the diagnosis and determines the type and extent of pericardial involvement. In this review, we elaborate upon various pericardial syndromes associated with different systemic autoimmune and autoinflammatory diseases and the multitude of imaging modalities that can be used to further characterize autoimmune pericardial involvement. Lastly, these forms of pericarditis have a greater likelihood of recurrence, and clinicians need to understand their unique treatment approaches to improve patient outcomes.
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Affiliation(s)
- Vardhmaan Jain
- Heart,Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Garvit Chhabra
- Department of Internal Medicine, University of Louisville, 530 S Jackson St, Louisville, KY 40202, USA
| | - Michael Chetrit
- Heart,Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Agam Bansal
- Heart,Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Felix Berglund
- Heart,Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Bryce Montanè
- Heart,Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Muhammad M Furqaan
- Heart,Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Salaam P Bachour
- Heart,Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Apostolos Kontzias
- Department of Rheumatology, Stony Brook University Hospital, 101 Nicolls Road, Stony Brook, NY 11794, USA
| | - Alexandra Villa-Forte
- Heart,Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Centre, 100 Woods Rd, Valhalla, NY 10595, USA
| | - Massimo Imazio
- University Division of Cardiology, Department of Medical Sciences, AOU Città della Salute e della Scienza di Torino, Corso Bramante, 88, 10126 Torino, TO, Italy
| | - Paul C Cremer
- Center for Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Allan L Klein
- Center for Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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5
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Alam L, Lasam G, Fishberg R. Pericardial effusion with tamponade – an uncommon presentation leading to the diagnosis of eosinophilic granulomatosis polyangiitis: A case report. World J Cardiol 2020; 12:460-467. [PMID: 33014293 PMCID: PMC7509990 DOI: 10.4330/wjc.v12.i9.460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/02/2020] [Accepted: 09/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Eosinophilic granulomatosis polyangiitis (EGPA) is a small vessel necrotizing vasculitis that commonly presents as peripheral eosinophilia and asthma; however, it can rarely manifest with cardiac involvement such as pericarditis and cardiac tamponade. Isolated pericardial tamponade presenting as the initial symptom of EGPA is exceedingly rare. Early diagnosis and appropriate treatment are crucial to prevent life-threatening outcomes.
CASE SUMMARY 52-year-old woman with no past medical history presented with progressive dyspnea and dry cough. On physical exam she had a pericardial friction rub and bilateral rales. Vital signs were notable for tachycardia at 119 beats per minute and hypoxia with 89% oxygen saturation. On laboratory exam, she had 45% peripheral eosinophilia, troponin elevation of 1.1 ng/mL and N-terminal prohormone of brain natriuretic peptide of 2101 pg/mL. TTE confirmed a large pericardial effusion and tamponade physiology. She underwent urgent pericardial window procedure. Pericardial and lung biopsy demonstrated eosinophilic infiltration. Based on the American College of Radiology guidelines, the patient was diagnosed with EGPA which manifested in its rare form of cardiac tamponade. She was treated with steroid taper and mepolizumab.
CONCLUSION This case highlights that when isolated pericardial involvement occurs in EGPA, diagnosis is recognized by performing pericardial biopsy demonstrating histopathologic evidence of eosinophilic infiltration.
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Affiliation(s)
- Loba Alam
- Department of Medicine, Atlantic Health System-Overlook Medical Center, Summit, NJ 07901, United States
| | - Glenmore Lasam
- Department of Cardiology, Icahn School of Medicine, Mount Sinai Heart at Mount Sinai Morningside, New York, NY 10025, United States
| | - Robert Fishberg
- Department of Cardiology, Atlantic Health System Overlook, Summit, NJ 07901, United States
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Zoubeidi H, Daoud F, Rachdi I, Somai M, Aydi Z, Ben Dhaou B, Boussema F. [A perimyocarditis revealing eosinophilic granulomatosis with polyangiitis]. Ann Cardiol Angeiol (Paris) 2020; 69:148-150. [PMID: 32265026 DOI: 10.1016/j.ancard.2019.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 09/20/2019] [Indexed: 06/11/2023]
Abstract
Churg-Strauss syndrome (CSS) or eosinophilic granulomatosis with polyangiitis is a systemic vasculitis characterized by necrotizing arteritis, eosinophilic infiltration and extravascular granuloma; that may involve several organs. Cardiac involvement is the first cause of death in this vasculitis. These include myocarditis, pericarditis, coronary heart disease, dysrhythmias, and rarely valvular involvement. We report the observation of CSS revealed by acute perimyocarditis.
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Affiliation(s)
- H Zoubeidi
- Service de médecine interne, hôpital Habib Thameur, 8, rue Ali Ben Ayed, 1008 Tunis, Tunisie; Faculté de médecine de Tunis, université de Tunis El Manar, Tunis, Tunisie
| | - F Daoud
- Service de médecine interne, hôpital Habib Thameur, 8, rue Ali Ben Ayed, 1008 Tunis, Tunisie; Faculté de médecine de Tunis, université de Tunis El Manar, Tunis, Tunisie
| | - I Rachdi
- Service de médecine interne, hôpital Habib Thameur, 8, rue Ali Ben Ayed, 1008 Tunis, Tunisie; Faculté de médecine de Tunis, université de Tunis El Manar, Tunis, Tunisie.
| | - M Somai
- Service de médecine interne, hôpital Habib Thameur, 8, rue Ali Ben Ayed, 1008 Tunis, Tunisie; Faculté de médecine de Tunis, université de Tunis El Manar, Tunis, Tunisie
| | - Z Aydi
- Service de médecine interne, hôpital Habib Thameur, 8, rue Ali Ben Ayed, 1008 Tunis, Tunisie; Faculté de médecine de Tunis, université de Tunis El Manar, Tunis, Tunisie
| | - B Ben Dhaou
- Service de médecine interne, hôpital Habib Thameur, 8, rue Ali Ben Ayed, 1008 Tunis, Tunisie; Faculté de médecine de Tunis, université de Tunis El Manar, Tunis, Tunisie
| | - F Boussema
- Service de médecine interne, hôpital Habib Thameur, 8, rue Ali Ben Ayed, 1008 Tunis, Tunisie; Faculté de médecine de Tunis, université de Tunis El Manar, Tunis, Tunisie
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7
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Jolobe OMP. Occam's Razor and Its Ethical Implications in Eosinophilic Granulomatosis With Polyangiitis. Am J Med 2019; 132:e811. [PMID: 31779784 DOI: 10.1016/j.amjmed.2019.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 07/04/2019] [Indexed: 11/17/2022]
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Yamamoto Y, Otani Y, Okabe F, Yoneda M, Morimura O, Abe K. Anti-proteinase 3-positive Eosinophilic Granulomatosis with Polyangiitis Revealed by Cardiac Tamponade. Intern Med 2019; 58:3045-3050. [PMID: 31243203 PMCID: PMC6859378 DOI: 10.2169/internalmedicine.2937-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare systemic vasculitis characterized by asthma, eosinophilia, and diffuse eosinophilic infiltration. Although cardiovascular involvement is common and a leading cause of EGPA-related mortality, severe pericarditis-led cardiac tamponade occurs rarely. We herein report a 72-year-old man with anti-proteinase 3 (anti-PR3) anti-neutrophil cytoplasmic antibody (ANCA)-positive EGPA diagnosed by the presence of cardiac tamponade, which responded quickly to pericardiocentesis and a single administration of prednisolone. This is the first case of anti-PR3 ANCA-positive EGPA with cardiac tamponade; the patient displayed clinical features of both ANCA-positive and ANCA-negative cases.
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Affiliation(s)
- Yuji Yamamoto
- Department of Internal Medicine, Toyonaka Municipal Hospital, Japan
| | - Yasushi Otani
- Department of Internal Medicine, Toyonaka Municipal Hospital, Japan
| | - Fukuko Okabe
- Department of Internal Medicine, Toyonaka Municipal Hospital, Japan
| | - Midori Yoneda
- Department of Internal Medicine, Toyonaka Municipal Hospital, Japan
| | - Osamu Morimura
- Department of Internal Medicine, Toyonaka Municipal Hospital, Japan
| | - Kinya Abe
- Department of Internal Medicine, Toyonaka Municipal Hospital, Japan
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Karthikeyan K, Balla S, Alpert MA. Non-infectious aortic and mitral valve vegetations in a patient with eosinophilic granulomatosis with polyangiitis. BMJ Case Rep 2019; 12:12/5/e225947. [PMID: 31092487 PMCID: PMC6536155 DOI: 10.1136/bcr-2018-225947] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare form of vasculitis characterised by atopic manifestations, inflammation of small-sized to medium-sized arteries and veins, hypereosinophilia and tissue infiltration with eosinophils. Cardiac complications occur most commonly in the absence of antineutrophil cytoplasmic antibodies. Cardiac complications include coronary arteritis (rare), pericarditis, myocarditis, endocardial fibrosis (Loeffler's endocarditis) and intracavitary thrombosis of the left or right ventricle. This is the first reported case of large non-infectious valvular vegetations associated with EGPA.
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Affiliation(s)
| | - Sudarshan Balla
- Cardiology, University of Missouri Health Care, Columbia, Missouri, USA
| | - Martin A Alpert
- Cardiology, University of Missouri-Columbia, Columbia, Missouri, USA
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Yano T, Ishimura S, Furukawa T, Koyama M, Tanaka M, Shimoshige S, Hashimoto A, Miura T. Cardiac tamponade leading to the diagnosis of eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome): a case report and review of the literature. Heart Vessels 2014; 30:841-4. [PMID: 25070496 DOI: 10.1007/s00380-014-0556-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Accepted: 07/11/2014] [Indexed: 12/15/2022]
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA), which was previously called Churg-Strauss syndrome, is a necrotizing systemic vasculitis of unknown cause accompanied by prominent eosinophilia. Cardiovascular complications, including eosinophilic myocarditis, are a major cause of mortality in this disorder. Acute pericarditis with slight pericardial effusion is a typical manifestation in EGPA, though hemodynamically significant pericardial effusion has been reported in a few cases. We report a case that initially presented with isolated cardiac tamponade, which was followed by systemic manifestations of EGPA over 3 weeks. Including the present case, previous EGPA cases with cardiac tamponade are reviewed to delineate its clinical characteristics.
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Affiliation(s)
- Toshiyuki Yano
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan.
| | - Shutaro Ishimura
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Tetsuaki Furukawa
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Masayuki Koyama
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Marenao Tanaka
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Shinya Shimoshige
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Tetsuji Miura
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
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11
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Chen MX, Yu BL, Peng DQ, Zhou SH. Eosinophilic myocarditis due to Churg-Strauss syndrome mimicking reversible dilated cardiomyopathy. Heart Lung 2013; 43:45-7. [PMID: 24157381 DOI: 10.1016/j.hrtlng.2013.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 09/26/2013] [Accepted: 09/26/2013] [Indexed: 10/26/2022]
Abstract
A 41-year-old woman with a history of asthma arrived at the emergency room of our hospital with dyspnea. The electrocardiogram showed no specific results. Echocardiography defects revealed an obvious decrease in the left ventricular systolic function and enlargement of the left chamber. We initially considered her condition to be dilated cardiomyopathy. However, she had eosinophilia in the peripheral blood and elevated cardiac enzymes. The coronary angiography showed normal coronary arteries. Single photon emission computed tomography (SPECT) showed infiltrative myocardial disease. She was then diagnosed with eosinophil infiltrations. Combined with peripheral nerve injury and lung involvement, she was diagnosed as having Churg-Strauss syndrome. After initiating prednisone treatment, her eosinophilia and rising cardiac enzymes recovered to normal, and both her echocardiographic abnormalities and symptoms noticeably improved.
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Affiliation(s)
- Ming-xian Chen
- Department of Cardiology, The Second Xiangya Hospital of Central South University, No. 139, Middle Ren-Min Road, Changsha, Hunan, People's Republic of China
| | - Bi-lian Yu
- Department of Cardiology, The Second Xiangya Hospital of Central South University, No. 139, Middle Ren-Min Road, Changsha, Hunan, People's Republic of China.
| | - Dao-quan Peng
- Department of Cardiology, The Second Xiangya Hospital of Central South University, No. 139, Middle Ren-Min Road, Changsha, Hunan, People's Republic of China
| | - Sheng-hua Zhou
- Department of Cardiology, The Second Xiangya Hospital of Central South University, No. 139, Middle Ren-Min Road, Changsha, Hunan, People's Republic of China
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12
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Churg–Strauss syndrome presenting with eosinophilic myocarditis: A diagnostic challenge. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2013. [DOI: 10.1016/j.repce.2012.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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13
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Correia AS, Gonçalves A, Araújo V, Almeida e Silva J, Pereira JM, Rodrigues Pereira P, Pizarro M, Silva JC, Maciel MJ. Churg-Strauss syndrome presenting with eosinophilic myocarditis: a diagnostic challenge. Rev Port Cardiol 2013; 32:707-11. [PMID: 23890465 DOI: 10.1016/j.repc.2012.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2012] [Revised: 09/22/2012] [Accepted: 10/12/2012] [Indexed: 10/26/2022] Open
Abstract
Churg-Strauss syndrome (CSS) is an unusual disease that presents as systemic vasculitis and peripheral eosinophilia in patients with an atopic constitution. Cardiac involvement is unusual and often not prominent on initial presentation, but is an important cause of morbidity and mortality in patients with CSS. We report the case of a young woman with severe acute myocarditis. Coronary arteriography demonstrated extensive focal vasculopathy, consistent with coronary vasculitis, and myocardial biopsy showed eosinophilic myocarditis. This presentation led to an initial diagnosis of CSS in this patient and appropriate therapy resulted in a spectacular remission of disease activity.
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Affiliation(s)
- Ana Sofia Correia
- Cardiology Department, Centro Hospitalar de São João, Porto, Portugal.
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[Cardiac tamponade and myocarditis in Churg-Strauss syndrome]. Ann Cardiol Angeiol (Paris) 2013; 63:271-5. [PMID: 23806862 DOI: 10.1016/j.ancard.2013.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 03/13/2013] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The successive occurrence of pericardial tamponade and myocarditis during a Churg-Strauss syndrome is exceptionally described. We report a patient in whom pericardial tamponade and myocarditis were the presenting manifestation of a Churg-Strauss syndrome. CASE REPORT A 58-year-old woman was admitted because of alteration of the clinical status with eosinophilia. One month ago, she was hospitalized for a pericardial tamponade treated by pericardial drainage. Acute myocarditis was diagnosed on chest pain during the second hospitalization. The etiologic inquiry ended in the diagnosis of Churg-Strauss complicated with a double cardiac involvement. A good response of clinical and biological anomalies was obtained after corticosteroid and immunosuppressive treatment. CONCLUSION Isolated or multiple involvements of cardiac tunics should lead to make diagnosis of systemic vasculitis. A complete initial assessment and a close observation of the patients followed for Churg-Strauss syndrome is imperative to detect a cardiac achievement and set up an early treatment.
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15
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Unrecognized tamponade diagnosed pre-induction by focused echocardiography. Can J Anaesth 2013; 60:803-7. [PMID: 23681721 DOI: 10.1007/s12630-013-9968-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 05/07/2013] [Indexed: 12/16/2022] Open
Abstract
PURPOSE We report a case of unrecognized cardiac tamponade diagnosed pre-induction by focused transthoracic echocardiography (TTE). The value of focused perioperative TTE, the anesthetic implications of Churg-Strauss syndrome, and the diagnosis of cardiac tamponade are discussed. CLINICAL FEATURES A 58-yr-old man with a history of severe asymptomatic aortic stenosis presented for elective endoscopic sinus surgery for intractable nasal polyps with recurrent sinusitis. His cardiologist and cardiac surgeon had recommended proceeding with surgery, as aortic valve replacement was not indicated because he was asymptomatic. Prior to induction, a focused TTE was performed by anesthesia in order to document the degree of aortic stenosis, baseline ventricular function, and baseline volume status. This provided a baseline for comparison in case the patient's hemodynamic status should deteriorate intraoperatively. Unexpectedly, the TTE examination revealed cardiac tamponade. After confirmation of the diagnosis by cardiology, urgent pericardiocentesis was performed. A diagnosis of Churg-Strauss syndrome was ultimately made, and the patient was treated with high-dose prednisone therapy. CONCLUSION Focused TTE has significant clinical utility for the diagnosis and assessment of hemodynamically significant cardiac conditions, particularly in the complex patient where clinical examination is challenging and echocardiographic findings can have immediate management implications.
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Suganuma K, Hashimoto T, Sato H, Suzuki T, Sakurai S. Oculomotor Nerve Palsy following Cardiac Tamponade with Churg-Strauss Syndrome: A Case Report. Case Rep Neurol 2011; 3:274-7. [PMID: 22125528 PMCID: PMC3224524 DOI: 10.1159/000334127] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
A 57-year-old man with a history of more than 10 years of bronchial asthma and chronic sinusitis complained of double vision which developed 18 days after cardiac tamponade with eosinophil-rich fluid (eosinophils 30%). He had oculomotor nerve palsy, and a blood test revealed eosinophilia (12,700/mm(3)) and elevation of both C-reactive protein and rheumatoid factor. He was diagnosed as having Churg-Strauss syndrome. His symptoms were relieved by corticosteroid therapy. Our case and previous cases in the literature revealed that oculomotor nerve palsy in Churg-Strauss syndrome is associated with pupil involvement and may be relieved by corticosteroid treatment.
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17
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Jayne D. Churg-Strauss syndrome. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00154-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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18
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Sauvetre G, Fares J, Caudron J, Dacher JN, Girszyn N, Daragon A, Levesque H, Marie I. Intérêt de l’imagerie par résonance magnétique nucléaire au cours de l’atteinte cardiaque du syndrome de Churg-Strauss. Trois observations et revue de la littérature. Rev Med Interne 2010; 31:600-5. [DOI: 10.1016/j.revmed.2010.04.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Revised: 03/08/2010] [Accepted: 04/10/2010] [Indexed: 10/19/2022]
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19
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Vinit J, Bielefeld P, Muller G, Pfitzenmeyer P, Bonniaud P, Lorcerie B, Besancenot JF. Heart involvement in Churg-Strauss syndrome: retrospective study in French Burgundy population in past 10 years. Eur J Intern Med 2010; 21:341-6. [PMID: 20603049 DOI: 10.1016/j.ejim.2010.05.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2009] [Revised: 04/29/2010] [Accepted: 05/10/2010] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Heart manifestations of Churg-Strauss syndrome (CSS) are varied. In the early stages of the disease, it is difficult to distinguish between lesions that are specific to CSS and those of other etiologies. The aim of our work was to compare the characteristics of patients with heart manifestations linked or not to Churg-Strauss syndrome. MATERIAL AND METHODS We recorded all clinical symptoms of patients with CSS hospitalized between 1998 and 2008 in Burgundy, France, and determined the possible relationships between heart symptoms and CSS. RESULTS From a cohort of 31 patients, we found 20 with heart lesions. When heart lesions were present, we noted fewer initial symptoms of digestive disorders (p<0.05), lower levels of lung infiltrates and fewer anti-MPO pANCA (p<0.05). Heart lesions were linked to CSS in 75% of cases. Their patients were thus younger than those in the other cardiac patients (p<0.05), were more likely to have clinical manifestations of heart involvement at diagnosis, were less likely to have lung infiltrates on the X-ray at diagnosis and during flare-ups and less likely to have lung abnormalities on X-rays during flare-ups (p<0.05) and higher level of leucocytes and eosinophils at diagnosis. CONCLUSION Heart lesions directly attributable to CSS are frequent, severe and probably underestimated. A specific physiopathology that is not mediated by ANCA seems to be involved in the genesis of CSS-related heart lesions.
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Affiliation(s)
- J Vinit
- Department of Internal Medicine and Systemic Diseases, General Hospital, University Hospital, 3 rue Faubourg Raines, Dijon Cedex, France.
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20
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Transient left ventricular dysfunction in Churg Strauss syndrome: a case report. CASES JOURNAL 2009; 2:6564. [PMID: 19829826 PMCID: PMC2740111 DOI: 10.4076/1757-1626-2-6564] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2009] [Accepted: 06/17/2009] [Indexed: 12/24/2022]
Abstract
A 42 year old woman was admitted to our hospital for investigation of eosinophilia. There were no findings from the physical examination of the lungs and heart. The echocardiography showed a segmental hypokinesia of the interventricular septum and the apex causing left ventricular dysfunction with an ejection fraction 45% and mild pericardial effusion. Cardiac magnetic resonance was performed, for detection of lesions associated with the underline disease, using electrocardiogram-triggered T2-weighted and T1-weighted multislice spin-echo images (before and after an intravenous bolus of gadolinium).The analysis of T2-weighted images revealed increased signal on the mid part of interventricular septum, suggesting myocardial oedema. In the delayed-enhanced images, areas of late phase gadolinium enhancement (indicative of fibrosis) were identified in the mid part of interventricular septum. Methylprednisolone therapy was started. The patient had follow-up echocardiographic examination every month and on sixth month improvement of left ventricular dysfunction was shown with an ejection fraction 55%.In conclusion our case is a typical Churg Strauss Syndrome with characteristic myocardial involvement which improved after corticosteroid treatment. The cardiac magnetic resonance has significant role for early and accurate detection and differentiation of myocardial damage even in preserved cardiac wall motion and cavity size.
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Neumann T, Manger B, Schmid M, Kroegel C, Hansch A, Kaiser WA, Reinhardt D, Wolf G, Hein G, Mall G, Schett G, Zwerina J. Cardiac involvement in Churg-Strauss syndrome: impact of endomyocarditis. Medicine (Baltimore) 2009; 88:236-243. [PMID: 19593229 DOI: 10.1097/md.0b013e3181af35a5] [Citation(s) in RCA: 154] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Cardiac disease is a major contributor to disease-related death in Churg-Strauss syndrome (CSS). We conducted the current study to determine the prevalence and clinical impact of cardiac involvement in CSS patients. We performed a multicenter, cross-sectional analysis of patients diagnosed with CSS. Cardiac workup included electrocardiography, echocardiography, cardiac magnetic resonance imaging (MRI), and endomyocardial biopsy.We analyzed 49 patients with CSS: 22 patients had clinical evidence of cardiac involvement. A negative antineutrophil cytoplasmic antibodies (ANCA) test and much higher eosinophil counts (9947 vs. 3657/microL, respectively, p < 0.001) distinguished patients with cardiac involvement from those without. Impaired left ventricular function (50%), mild to severe valvular insufficiencies (73%), and pericardial effusions (41%) were common findings in these patients. Endomyocarditis was found in 13 patients (59%) as detected by cardiac MRI, cardiac thrombus formation, and endomyocardial biopsy, and was associated with impaired cardiac function. After a mean follow-up of 47 months, most patients had regained or maintained good cardiac function. However, patients with endomyocarditis had a more severe outcome. Two patients died (61 and 99 mo after diagnosis, respectively), both due to severe cardiomyopathy and heart failure.Cardiac involvement is common in patients with CSS and is associated with the absence of ANCA and high eosinophil counts. Endomyocarditis may represent the most severe manifestation eventually causing fatal outcome. A structured clinical assessment incorporating cardiac imaging with echocardiography and MRI can identify impaired cardiac function and endomyocardial abnormalities.
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Affiliation(s)
- Thomas Neumann
- From Department of Internal Medicine 3 (TN, GW, GH), Department of Internal Medicine 1 (CK), and Institute of Diagnostic and Interventional Radiology (AH, WAK), University of Jena, Jena; Department of Internal Medicine 3 and Institute for Clinical Immunology (BM, GS, JZ), and Department of Internal Medicine 2 (MS), University of Erlangen-Nuremberg, Erlangen; Department of Cardiology (DR), Evangelisches Krankenhaus, Hamm; and Institute of Pathology (GM), Klinikum Darmstadt, Darmstadt, Germany
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Al-Ammar AY, Yasin SS, Al-Muhsen SZ, Al-Saadi MM, Al-Sohaibani MO. A laryngeal presentation of Churg-Strauss syndrome in childhood. Ann Saudi Med 2009; 29:142-5. [PMID: 19318743 PMCID: PMC2813625 DOI: 10.4103/0256-4947.51807] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A 10- year-old female, known to have bronchial asthma, presented with an unusual laryngeal lesion, eventually diagnosed as Churg-Strauss syndrome (CSS). She was referred to our hospital with history of recurrent stridor. On endoscopyhe, the larynx showed signs similar to recurrent respiratory papillomatosis (RRP). CSS is a systemic disorder and is now defined as one of the ANCA ( antineutrophil cytoplasmic antibodies)-associated vasculitides. CSS is a systemic disease that may involve unusual sites like the larynx. Such an unusual presentation of CSS should be kept in mind, especially in patients with history of asthma.
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Affiliation(s)
- Ahmed Y Al-Ammar
- Department of Otolaryngology, King Abdulaziz University Hospital, Riyadh, Saudi Arabia.
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Acute Chest Pain, Heart Failure, and Eosinophilia in a Woman Without Coronary Disease. Cardiovasc Intervent Radiol 2009; 32:1272-4. [DOI: 10.1007/s00270-009-9516-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Revised: 01/01/2009] [Accepted: 01/06/2009] [Indexed: 10/21/2022]
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Corradi D, Maestri R, Facchetti F. Postpartum Churg-Strauss syndrome with severe cardiac involvement: description of a case and review of the literature. Clin Rheumatol 2009; 28:739-43. [PMID: 19238502 DOI: 10.1007/s10067-009-1143-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2008] [Accepted: 02/12/2009] [Indexed: 01/11/2023]
Abstract
Churg-Strauss syndrome (CSS) is a rare small- or intermediate-vessel necrotizing vasculitis typically characterized by asthma, lung infiltrates, necrotizing granulomas, and hypereosinophilia. In this report, we describe the case of a 35-year-old woman who, during her third trimester of pregnancy, developed dyspnea and, after delivery, severe cardiac failure which required heart transplantation. Diagnosis of CSS was made after performing a myocardial biopsy. We have also undertaken a review of the English-language literature regarding previously reported cases of pregnancies in women suffering from Churg-Strauss syndrome with particular attention to those patients with cardiovascular involvement.
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Affiliation(s)
- Domenico Corradi
- Department of Pathology and Laboratory Medicine, Section of Pathology, University of Parma, Via Gramsci 14, 43100, Parma, Italy.
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Churg-Strauss syndrome: a rare presentation with otological and pericardial manifestations: case report and review of the literature. Clin Rheumatol 2009; 28 Suppl 1:S35-8. [PMID: 19225706 DOI: 10.1007/s10067-009-1119-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2008] [Accepted: 01/29/2009] [Indexed: 12/17/2022]
Abstract
Churg-Strauss syndrome (CSS) is a rare multisystem autoimmune disease characterized by diffuse eosinophilic infiltration and necrotizing vasculitis. There are typical manifestations of longstanding rhinosinusitis and polyposis but otological manifestations are rare and characterized by dense aural discharge, granulomatous eosinophilic infiltrate in the mastoid and middle ear with conductive hearing loss, and progressive sensory neural hearing loss--all of which are not responsive to conventional treatment. We describe the case of a 59-year-old man with a rare presentation of CSS that included chronic bilateral otitis media with hearing loss and life-threatening pericardial tamponade. Treatment with pericardiocentesis, prednisone and cyclophosphamide was beneficial and resulted in an improvement of the pericardial and otological manifestations. Early recognition and treatment of otological involvement in CSS is extremely important because of the dramatic response to corticosteroids which may prevent progression of hearing loss.
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Chung KY, Kim HK, Yoon JY, Kim WS. Cholecystectomy of a patient with Churg-Strauss syndrome: A case report. Korean J Anesthesiol 2009; 57:749-753. [PMID: 30625960 DOI: 10.4097/kjae.2009.57.6.749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Churg-Strauss syndrome is an allergic granulomatous angitis and the organ most commonly involved in this condition is the lung. However, this syndrome also affects the skin, cardiovascular system, kidney, peripheral nervous system and gastrointestinal system. Cardiac involvement is a rare complication but can lead to rapid-onset heart failure as the result of specific cardiomyopathy. Pericardial effusion may also occur. Acalculous cholecystitis is also a rare complication of Churg-Strauss syndrome. Here, we present a case of a patient with Churg-Strauss syndrome and severe heart failure scheduled for cholecystectomy due to acalculous cholecystitis. The patient had mild asthma symptoms, peripheral neuritis in both legs, and severe heart failure. During the preoperative period, steroids, beta2 agonists, diuretics, and antihypertensive drugs were administered. During anesthesia we attempted to prevent compromising the patient's cardiac and pulmonary functions. The surgery was completed successfully, and the patient was discharged without any complications.
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Affiliation(s)
- Kyu Yeon Chung
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Busan, Korea.
| | - Hae Kyu Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Busan, Korea.
| | - Ji Young Yoon
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Busan, Korea.
| | - Won Sung Kim
- Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Busan, Korea.
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Jalal Z, Ghiringhelli C, Toulmonde M, Lafitte A, Tombrey T, Le Metayer P, Osorio Perez F, Longy-Boursier M, Mercie P. Atteinte cardiaque au cours du syndrome de Churg et Strauss. Rev Med Interne 2008. [DOI: 10.1016/j.revmed.2008.03.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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28
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Current World Literature. Curr Opin Rheumatol 2008; 20:111-20. [DOI: 10.1097/bor.0b013e3282f408ae] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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