A case of Churg-Strauss syndrome with necrotizing crescentic glomerulonephritis accompanied by acute coronary syndrome due to vasospasm

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.

Immunosuppressive therapy ameliorates refractory vasospastic angina, severe pulmonary hypertension, and bronchiolitis in a patient with eosinophilic granulomatosis with polyangiitis: a case report

Introduction

Eosinophilic granulomatosis with polyangiitis (EGPA) is characterized by tissue and blood eosinophilia, vasculitis of small to medium-sized vessels, and allergy symptoms, and can cause various manifestations, including heart, lung, gastrointestinal, skin, and peripheral nerve disorders.

Case presentation

A 34-year-old woman with a history of asthma, nasal polyp, and sinusitis presented with ventricular fibrillation after severe chest pain. Emergent coronary angiography showed no coronary stenosis. After admission, she suffered from hypoxaemia and recurrent chest pain with ST-segment changes, suggesting vasospastic angina (VSA). Chest computed tomography (CT) showed centrilobular nodular shadows, suggesting bronchiolitis. Since she had hypereosinophilia, we administered oral prednisolone, which resulted in improvements of hypereosinophilia, hypoxaemia, and recurrent chest pains in 3 days. Right heart catheterization showed severe pulmonary hypertension (PH) with a mean pulmonary artery pressure (mPAP) of 48 mmHg and pulmonary vascular resistance (PVR) of 12 Wood units (WU). Ergonovine provocation test induced severe diffuse spasm of the left coronary artery including the left main trunk. Based on asthma, sinusitis, hypereosinophilia, and chest CT findings, the diagnosis of EGPA associated with VSA and PH was made. Thereafter, we started intravenous cyclophosphamide (IV-CY) pulse therapy in addition to prednisolone and pulmonary vasodilators. Six months after IV-CY therapy, mPAP and PVR decreased to 34 mmHg and 5.1 WU, respectively. Moreover, repeated ergonovine provocation test was negative without coronary spasm or electrocardiogram (ECG) changes.

Discussion

This case indicates that EGPA can cause severe PH, refractory VSA, and bronchiolitis, which could be markedly improved by treating underlying conditions with immunosuppressive therapy.

Recurrent variant angina pectoris due to Behçet's syndrome

We report a case of recurrent variant angina pectoris which occurred even while receiving antispastic treatment. Coronary angiography revealed no obvious lesion. Behçet's syndrome was diagnosed based on recurrent oral aphthous and genital ulcer as well as skin manifestation. After treatment with immunosuppressant, neither angina nor oral ulcer relapsed. We strongly believe that the variant angina is due to coronary vasospasm induced by Behçet's syndrome in this patient.