Endomyocardial fibrosis and eosinophilia

Endomyocardial fibrosis

Background

Endomyocardial fibrosis (EMF) is a neglected cardiovascular disease of poverty which carries a poor prognosis with no specific treatment affecting mainly children and young adults. Here, we report our 10-year experience in the therapeutic management and surgical treatment for EMF.

Methods

From February 2009 to 2019 March, 55 patients diagnosed with EMF from our cardiology unit underwent surgical repair at our department's pediatric surgical division. There were 35 male, and 20 female patients whose ages varied from 1 year 2 months to 12 years mean age 5.7 (±3.2). We designed the study aimed at assessing the cardio-structural abnormalities and coronary vascular changes faced with EMF patients using echocardiography, and coronary angiography with a detailed and thorough surgical examination of each case.

Results

Of the 55 operated patients, 1 had mild lesions, 26 had moderate lesions, and 28 had severe heart disease. All but one patient was in NYHA functional class III or IV at the time of surgery. All but one female patient with mild ventricular lesions and no valvular involvement had severe atrioventricular valve regurgitation with valves considered suitable for both replacements; 45 patients mean age 6.0 (±3.1) and repair nine patients mean age 3.8 (±2.9). The mean endocardial thickness was 3,000 (±1519) µm.

Conclusions

The echocardiographic changes corresponded well to the findings on surgery and histopathology. The coronary changes seen included a spectrum of fibrin deposition, medial sclerosis and degeneration, and the formation of plexiform lesions. Surgically evaluating the resected cardiac tissue might help improve disease management.

Endomyocardial fibrosis in Sudan: clinical and echocardiographic features

Objective:

Endomyocardial fibrosis (EMF) is a rare disease and is often an underdiagnosed and forgotten cardiomyopathy. The objective of this study was to document the current frequency of EMF in Sudan by defining and selecting cases from patients attending the echocardiography laboratory. Additionally we aimed to create an EMF registry for Sudan.

Methods:

The study started in January 2007 and is on-going. All the patients attending our echocardiography clinics in four different hospitals in Khartoum, Sudan, were included. Transthoracic echocardiography was used as the main diagnostic and selection tool. The diagnosis of EMF was based on predefined criteria and definitions, and was further supported by additional clinical, ECG, laboratory and chest X-ray findings.

Results:

Out of 4 332 cases studied, 23 (0.5%) were found to have features of EMF. Females constituted 52% and the age range was 24 to 67 years. All patients presented with dyspnoea grades III–IV. Advanced heart failure with gross fluid overload was seen in 54% of cases and ascites was seen in 30%. EMF was biventricular in 53%, left ventricular in 29% and right ventricular in 18% of cases. Apical and ventricular wall fibrosis was found in all cases, followed by atrial enlargement, atrioventricular valve incompetence, ventricular cavity obliteration, restrictive flow pattern and pericardial effusion. Additional echocardiographic features are defined and discussed.

Conclusion:

Although a rare disease, cases of EMF can be identified in Sudan if a high index of suspicion is observed. New echocardiographic features of ventricular wall layering, endocardial fibrous shelf and endomyocardiopericarial fibrosis were identified and are discussed.

Endomyocardial involvement in asymptomatic sub-Saharan immigrants with helminth-related eosinophilia

Background

Among immigrants of sub-Saharan origin, parasitic infection is the leading cause of eosinophilia, which is generally interpreted as a defense mechanism. A side effect of the inflammatory mediators released by eosinophils is damage to host organs, especially the heart. The main objectives of this study were to i) assess cardiac involvement in asymptomatic sub-Saharan immigrants with eosinophilia, ii) relate the presence of lesions with the degree of eosinophilia, and iii) study the relationship between cardiac involvement and the type of causative parasite.

Methodology/Principle findings

In total, the study included 50 black immigrants (37 patients and 13 controls) from sub-Saharan Africa. In all subjects, heart structure and function were evaluated in a blinded manner using Sonos 5500 echocardiographic equipment. The findings were classified and described according to established criteria. The diagnostic criteria for helminthosis were those reported in the literature. Serum eosinophil-derived neurotoxin levels were measured using enzyme-linked immunosorbent assay. A significant association was found between the presence of eosinophilia and structural alterations (mitral valve thickening). However, the lack of an association between the degree of eosinophilia and heart valve disease and the absence of valve involvement in some patients with eosinophilia suggest the role of other factors in the appearance of endocardial lesions. There was also no association between the type of helminth and valve involvement.

Conclusions

We, therefore, suggest that transthoracic echocardiography be performed in every sub-Saharan individual with eosinophilia in order to rule out early heart valve lesions.

Endomyocardial fibrosis is characterized by fibrosis of the apical endocardium of the right ventricle, left ventricle, or both. Epidemiological studies of endomyocardial fibrosis indicate a predominance in tropical regions, with young people and men being affected predominantly. Little is known about the natural history and pathogenic factors of this condition. One of the most important factors is the presence of eosinophilia, which is mainly related to helminth infections. The aim of the study was to evaluate cardiac involvement in patients with absolute eosinophilia. We performed an echocardiographic study in asymptomatic sub-Saharan immigrants with eosinophilia and compared them with a group of control patients from the same region and of the same age. Our results suggest that eosinophilia associated with helminth infection (regardless of the causative microorganism) contributes to the asymptomatic phases of endomyocardial involvement. Treatment of these infections is simple, effective, and economical. Therefore, we suggest that all immigrant patients with eosinophilia undergo etiologic study and causal treatment as well as transthoracic echocardiography in order to rule out early damage.

[Endomyocardial fibrosis in Cameroon: Echocardiographic and clinical description of a pediatric series in Yaoundé]

BACKGROUND

Endomyocardial fibrosis is a restrictive cardiomyopathy that causes heart failure. It is characterized by the fibrotic thickening of the endocardium, sometimes involving the myocardium as well. The lesion generally lies at the apices or inflow tracts of one or both ventricles, associated with more or less severe alteration of the valves. It is a disease of the intertropical regions but is not well known in Cameroon. In this study we describe the first series seen in a pediatric hospital in Cameroon.

PATIENTS AND METHODS

A retrospective study was conducted in a pediatric hospital in Yaoundé involving children who had been diagnosed with endomyocardial fibrosis after echocardiographic investigation. We collected the clinical and paraclinical data from consultation records and medical files.

RESULTS

Between January 2006 to December 2013, we registered 1430 patients with a cardiac anomaly in our center. Endomyocardial fibrosis was found in 46 patients. Neither sex predominated. Ages at the time of diagnosis varied between 2 and 17 years. Most of the patients were between 5 and 15 years old (80.4 %), with a median of 10 years (interquartile range, 7-13 years). The main complaints were breathlessness, cough, abdominal distension, abdominal, and loss of appetite. Apart from the hyperpigmentation of the lips observed in all our patients, dyspnea was the most frequent physical sign and the diagnosis was made at a time when signs of heart failure were preponderant. Growth retardation was found in all the children examined. All patients were underweight with a median weight for age found below the 25th percentile of the norms according to the National Health Statistics. Lower limb edema was absent even in the presence of voluminous ascites. All subjects had hyperpigmented lips. Despite the cyanotic appearance of the lips, pulse oximetry always gave a normal oxygen saturation level and no cyanosis was seen elsewhere. None of the patients had nail clubbing. Fibrosis more often affected the right ventricle (45/46 patients). The apical obliteration by fibrotic material was found in 43 (93.5 %) patients. Moreover, 36 (78.3 %) patients had pericardial effusion: mild to moderate in 32 subjects and abundant in four subjects. Hypereosinophilia was noted in 57.5 % of the patients. Atrial fibrillation was found in six out of 15 patients who had an electrocardiogram done.

CONCLUSION

The modes of clinical presentation of endomyocardial fibrosis are not sufficiently well known in our context. Despite its insidious progression, certain signs such as weight loss and hyperpigmented lips could be very helpful for screening and easing orientation of parents and heath personnel, thus enabling early referral for appropriate investigation. The presence of bulky ascites without edema of the lower extremities should be viewed as strongly suggestive.

Plasma cytokine profile in tropical endomyocardial fibrosis: predominance of TNF-a, IL-4 and IL-10

Background

The participation of immune/inflammatory mechanisms in the pathogenesis of tropical endomyocardial fibrosis (EMF) has been suggested by the finding of early blood and myocardial eosinophilia. However, the inflammatory activation status of late-stage EMF patients is still unknown.

Methodology/Principal findings

We evaluated pro- and anti-inflammatory cytokine levels in plasma samples from late stage EMF patients. Cytokine levels of Tumor Necrosis Factor (TNF)-α, Interferon (IFN)-γ, Interleukin (IL)-2, IL-4, IL-6, and IL-10 were assayed in plasma samples from 27 EMF patients and compared with those of healthy control subjects. All EMF patients displayed detectable plasma levels of at least one of the cytokines tested. We found that TNF-α, IL-6, IL-4, and IL-10 were each detected in at least 74% of tested sera, and plasma levels of IL-10, IL-4, and TNF-α were significantly higher than those of controls. Plasma levels of such cytokines positively correlated with each other.

Conclusions/Significance

The mixed pro- and anti-inflammatory/Th2circulating cytokine profile in EMF is consistent with the presence of a persistent inflammatory stimulus. On the other hand, the detection of increased levels of TNF-α may be secondary to the cardiovascular involvement observed in these patients, whereas IL-4 and IL-10 may have been upregulated as a homeostatic mechanism to buffer both production and deleterious cardiovascular effects of pro-inflammatory cytokines. Further studies might establish whether these findings play a role in disease pathogenesis.

Endomyocardial fibrosis: A form of endemic restrictive cardiomyopathy

Endomyocardial fibrosis is a form of endemic restrictive cardiomyopathy that affects mainly children and adolescents, and is geographically restricted to some poor areas of Africa, Latin America and Asia. It is a condition with high morbidity and mortality, for which no effective therapy is available. Although several hypotheses have been proposed as triggers or causal factors for the disease, none are able to explain the occurrence of the disease worldwide. In endemic areas of Africa endomyocardial fibrosis is as common a cause of heart failure as rheumatic heart disease, accounting for up to 20% of cases of heart failure and imposes a considerable burden to the communities and the health systems. However, due to lack of resources for research in these areas, the exact epidemiology, etiology and pathogenesis remain unknown, and the natural history is incompletely understood. We here review the main aspects of epidemiology, natural history, clinical picture and management of endomyocardial fibrosis, proposing new ways to increase research into this challenging and neglected cardiovascular disease.

Eosinophils and disease pathogenesis

Eosinophils are granulocytic innate immune cells whose presence is conspicuous in a variety of disease states, including eosinophilic hyperproliferative and infiltrative processes, as well as conditions associated with maladaptive Th2 inflammation. This review discusses the role of eosinophils in disease pathogenesis, including a consideration of relevant eosinophil biology. Eosinophilic disease patterns of tissue infiltration are also detailed, as are candidate mechanisms by which eosinophils cause fibrosis and hypercoagulability and the importance of eosinophils in allergic inflammation. Eosinophils are unique cells in their spectrum of associated disease, with the promise of future discoveries in delineating the manner in which they contribute to disease pathogenesis.

Endomyocardial fibrosis: still a mystery after 60 years

The pathologist Jack N. P. Davies identified endomyocardial fibrosis in Uganda in 1947. Since that time, reports of this restrictive cardiomyopathy have come from other parts of tropical Africa, South Asia, and South America. In Kampala, the disease accounts for 20% of heart disease patients referred for echocardiography. We conducted a systematic review of research on the epidemiology and etiology of endomyocardial fibrosis. We relied primarily on articles in the MEDLINE database with either “endomyocardial fibrosis” or “endomyocardial sclerosis” in the title. The volume of publications on endomyocardial fibrosis has declined since the 1980s. Despite several hypotheses regarding cause, no account of the etiology of this disease has yet fully explained its unique geographical distribution.

Pitfalls in diagnosis and clinical, echocardiographic, and hemodynamic findings in endomyocardial fibrosis: a 25-year experience

Endomyocardial fibrosis (EMF) is a fascinating disease entity of unknown etiology. It is prevalent in the tropical zone. Its essential features are the formation of fibrous tissue on the endocardium and to a lesser extent in the myocardium of the inflow tract and apex of one or both ventricles. It results in endocardial rigidity, atrioventricular valve incompetence secondary to papillary muscle involvement, and progressive reduction of the cavity of the involved ventricle leading to restriction in filling and atrial enlargement. This article will present 21 patients with EMF who were initially referred to our hospital from 1979 to 2004 with different diagnoses: rheumatic heart disease with mitral and or tricuspid regurgitation (n = 9), constrictive pericarditis (n = 6), restrictive cardiomyopathy (n = 1), hypertrophic cardiomyopathy apical type (n = 2), dilated cardiomyopathy (n = 2), and Ebstein malfunction of the tricuspid valve (n = 1). The clinical, echocardiographic, hemodynamic, and angiographic findings in these 21 patients are presented; echocardiographic findings lead to the right diagnosis. The presence of a small ventricle with obliteration of the apex and large atrium shown on two-dimensional echocardiography is highly suggestive of EMF.

Helminth associated hypereosinophilia and tropical endomyocardial fibrosis (EMF) in Nigeria

There should be a recognisable trend between the incidence of hypereosinophilia and the duration of tropical endomyocardial fibrosis (EMF), if the hypothesis, that EMF is the burnt out phase of eosinophil associated heart disease, is correct. We tested this hypothesis in a prospective study of 89 consecutive EMF cases over an 18 year period at two Nigerian locations (Ife in South West and Calabar in South East). We carefully dated the duration of EMF symptoms at first presentation and screened for hypereosinophilia (eosinophilia > or = 1500/mm3), and their causes. When no cause was identified for hypereosinophilia we gave a therapeutic trial with diethylcarbamazine to the patients. An eosinophil count > or = 1000/mm3 was recorded in 80% of 24 cases seen within 6 months; 55% of 46 cases seen 0-24 months; 54% of 18 cases seen 25-48 months and 21% of 25 cases seen more than 49 months of onset of symptoms: while the respective distribution of eosinophil count > or = 1500/mm3 for similar periods were 66, 44, 27 and 21%. This reflects a highly significant (P < 0.001) inverse relationship between hypereosinophilia and the duration of EMF and strengthens the concept that EMF (without eosinophilia) represents the late stage of eosinophilic heart disease. The localisation of endemic EMF to the low-lying tropical rain forest Zone and its predominant occurrence among rural dwellers and farmers suggest a vector borne etiologic agent. Microfilaria was the most likely cause of hypereosinophilia in the cases presented.

Endomyocardial fibrosis: Clinical, echocardiographic and hemodynamic findings

Endomyocardial fibrosis (EMF) is a disease of unknown origin. It was first described by Davies in Uganda in 1948. The clinical enchocardiographic, and hemodynamic findings in 18 patients are presented. Six patients had right-sided involvement, four had left-sided involvement and eight had biventricular involvement. The presence of a small ventricle with obliteration of the apex and a large atrium, diagnosed by two-dimensional echocardiography, is highly suggestive of endomyocardial fibrosis. Ventricular angiography was diagnostic in 17 out of 18 cases. Endomyocardial biopsy yielded positive findings in three out of seven patients and is not essential for diagnosis. Two patients suffered a cerebral embolism. Six patients underwent surgery with good results in three patients.

Loeffler's fibroplastic endocarditis

The hypereosinophilia syndrome with cardiac involvement, as an incidental autopsy finding in a 50-yr-old male, is reported. A review of the literature on the clinical manifestations, pathologic findings, differential diagnosis, associated conditions, pathogenesis of the cardiac involvement, and the role of palliative treatment is presented.

Endomyocardial fibrosis: report of eight cases

Endomyocardial fibrosis is a disease of unknown origin which has not previously been described in detail from the Middle East. The clinical, echocardiographic, hemodynamic and angiocardiographic findings in eight patients (five men and three women, mean age 38 years) are presented. Two patients had right-sided involvement, two had left-sided involvement and four had biventricular involvement. The presence of a small ventricle with obliteration of the apex and a large atrium is a two-dimensional echocardiographic finding highly suggestive of endomyocardial fibrosis. Hemodynamic characteristics of dip and plateau on ventricular pressure curves were present in six patients. Ventricular angiography was diagnostic in all cases. Endomyocardial biopsy yielded positive findings in three of six patients and is not essential for diagnosis.

Eosinophilic disorders affecting the myocardium and endocardium: a review

A wide range of disorders give rise to eosinophil counts greater than 1.5 X 10(9)/l (hypereosinophilia) and cardiac injury. The best known of these is eosinophilic endomyocardial disease (Löffler's endomyocardial fibrosis), which occurs as a major complication of the idiopathic hypereosinophilic syndrome. Here the heart damage appears to be a direct result of tissue injury produced by toxic eosinophil granule proteins within the heart. However, it is not known what causes the eosinophilia in these patients, why the eosinophils degranulate, or why the endocardium is especially susceptible to this type of injury. A number of parasitic infections may give rise to eosinophilic myocarditis. This is usually the result of the presence of the parasites within the myocardium where they die within inflammatory lesions, which may be extensive. Occasionally, drug reactions and rejection of a transplanted heart may produce eosinophilic myocarditis. Allergic granulomatosis and vasculitis (the Churg-Strauss syndrome), which gives rise to granulomas involving the myocardium, and eosinophilic (hypersensitivity) myocarditis usually respond rapidly to treatment with steroids. However, diffuse myocardial involvement may lead to heart failure, and some of these patients may later develop dilated cardiomyopathy. It is concluded that the heart may be affected by a variety of diseases in which eosinophils are a prominent component in the inflammatory cell infiltrates. Eosinophils themselves may contribute to some of the myocardial cell injury which occurs in these diseases, and attempts to limit this with steroids may be worthwhile in some patients.

A comparison of the clinical and cardiological features of endomyocardial disease in temperate and tropical regions

This study was designed to compare the clinical and cardiological features of endomyocardial disease in temperate and tropical regions. Eleven patients were studied in the U.K., 47 in India and 8 in Brazil. The patients in the U.K. were older, with a male predominance, and they had a systemic illness: the hypereosinophilic syndrome. Half of these patients presented in the early necrotic stage of the disease, and all had biventricular involvement. On the other hand, patients in the tropical countries were younger, with an equal sex incidence, and were from poor, malnourished communities with heavy parasite loads, especially filariasis in India. None presented in the early necrotic stage of the disease and a quarter had isolated right or left ventricular disease. In order to account for these differences between patients in temperate and tropical regions with endomyocardial disease, it was proposed that the nature of the underlying disease and the rate at which endomyocardial lesions develop, determine the clinical features of this disorder. In temperate climates eosinophil granule toxins may produce a rapidly progressive form of the disease in patients with the hypereosinophilic syndrome, whereas the disease may take longer to develop in patients in tropical climates, who have a less marked eosinophilia due to parasitic infections.

Pathological aspects of endomyocardial fibrosis

The studies leading up to the unitarian concept suggesting that endomyocardial fibrosis, described in the tropics, and Löffler's endocarditis parietalis fibroplastica (Löffler's endomyocardial disease), described in the temperate zone, belong to the same disease spectrum are detailed. Evidence that the eosinophil is involved in the pathogenesis of endomyocardial diseases, irrespective of the geographical origin, is presented. The findings of a similar abnormality in these cells obtained from patients in the tropical and temperate zones are briefly mentioned. In view of the evidence it is proposed that endomyocardial disease, associated with abnormal eosinophils, hitherto classified under the restrictive type of cardiomyopathy, be removed from this classification and reclassified under 'specific heart muscle disease'.

Mitral annuloplasty in endomyocardial fibrosis: an alternative to valve replacement

The case of a patient with left ventricular endomyocardial fibrosis (EMF) causing severe mitral regurgitation is presented. Excision of the fibrotic tissue through the left atrium and mitral annuloplasty resulted in symptomatic relief and uncomplicated pregnancy. An X-linked congenital dermatological condition, Bloch-Sulzberger syndrome (incontinentia pigmenti), associated with chronic eosinophilia, was also present. This occurrence with EMF has not previously been reported. Atrioventricular valve reconstruction is a feasible alternative to valve replacement in EMF.

Relation of severe eosinophilia and microfilariasis to chronic African endomyocardial fibrosis

Over a two-year period, 44 patients had an eosinophil count above the 97th centile. Thirteen of these 44 had heart disease presenting within six months of the onset of symptoms. Microfilariasis was the most likely cause of the raised total eosinophil in these 13 patients. In all, the raised eosinophil count we returned to normal by the use of diethylcarbamazine (Banocide). Eleven of the 13 were followed up and eight of them (73%) developed clinical features of cardiac constriction and tricuspid regurgitation. The mean duration of follow-up was two years. Limited cardiac catheterisation studies in six of the patients showed evidence of constriction or of tricuspid regurgitation. The clinical features of these eight patients were indistinguishable from those found in chronic endomyocardial fibrosis. This disease was further suggested by recurrent cerebral embolism in one, and a large pericardial effusion in another; and it was also present in the one patient to come to necropsy. Thus, microfilaria-induced eosinophilia, when high, is frequently associated with heart disease which appears to be chronic endomyocardial fibrosis many months after the eosinophilia has returned to normal.

Constrictive endocarditis. Report of a case with successful surgery

An 18-year old white youth presented with severe right heart failure and was found to have an obliterated and funnel-shaped right ventricle, massive tricuspid regurgitation, and mitral regurgitation. The haemodynamic findings were those of cardiomyopathy with obliteration on the right side. He underwent surgery consisting of decortication and peeling off of a thickened right ventricular endocardium, tricuspid valve replacement, and mitral valve repair. After surgery there was pronounced haemodynamic as well as clinical improvement. The pathological picture was that of constrictive endocarditis. We recommend this method of treatment for patients with obliterate cardiomyopathy on either side of the heart.

Löffler's endocarditis and endomyocardial fibrosis--a nosologic entity?

The problem whether Löffler's endocarditis and endomyocardial fibrosis belong to the same disease spectrum or are separate entities is still under debate. Until recently it was believed that endomyocardial fibrosis was a disorder restricted to tropical areas. Three Danish patients are presented, two showing a continuous disease spectrum, one patient showing the fully developed endomyocardial fibrosis which is indistinguishable from endomyocardial fibrosis described from the tropical areas. Eosinophilia was present in all three patients. The findings described in these three patients lend support to the unitarian hypothesis that Löffler's endocarditis and endomyocardial fibrosis belong to the same disease spectrum, and that the eosinophilic granulocyte may be the underlying cause.