Hypereosinophilic syndrome with biventricular involvement

Sudden unexpected death in childhood due to eosinophilic myocarditis

A 12-year-old boy with no previous serious medical history experienced abdominal discomfort and chest pains for 5 days and suddenly died. The autopsy revealed diffuse and extensive infiltration of eosinophils into the myocardium, with poorly formed granulomas and few fibrotic changes. The necrotic changes was so extensive that Charcot-Leyden crystals formed. The other visceral organs had no specific pathologic changes except for mild lymphocytic infiltration with an increase in goblet cells in the bronchial areas and eosinocytosis in the blood vessels. An initial viral infection seemed to have caused subsequent eosinophil activation due to an allergic condition. Eosinophilic myocarditis is a rare cause of sudden death in apparently healthy children. Cardiac toxicity of eosinophils is, however, well established and dominates the ultimate prognosis of patients with complicated eosinophilia.

A case of hypereosinophilic syndrome with asymmetric septal hypertrophy

A case of idiopathic hypereosinophilic syndrome (HES) with asymmetric septal hypertrophy (ASH) is described: this is a very rare association. The patient was a 56-year-old male with hypereosinophilia lasting for 10 years. The white blood cell count was 11200/mm3, with 22% eosinophils, and eosinophilic hyperplasia (7.2%) was noted in the bone marrow. A peripheral blood smear showed vacuolated eosinophils with a reduced content of granules. An ultrastructure study of the eosinophils revealed reduced numbers of crystalloid granules which appeared to be dissolving with reversal of normal staining. An echocardiogram and a biventriculoglam indicated ASH with the interventricular septal wall thickness of 2.4 cm and the left ventricular posterior wall thickness of 1.5 cm. Right ventricular endomyocardial biopsy revealed no eosinophilic infiltration, but endocardial thickening, subendocardial fibrosis, hypertrophy, myocytolysis, and fragmentation of muscle bundles were observed.

Severe constrictive pericarditis as an unsuspected cause of death in a patient with idiopathic hypereosinophilic syndrome and restrictive cardiomyopathy

A 43-year-old man with idiopathic hypereosinophilic syndrome survived a relatively long term (6 1/2 years) before he succumbed to intractable heart failure. Six months before death, his chronic heart failure from restrictive cardiomyopathy was well compensated. Autopsy demonstrated severe constrictive pericarditis which was not suspected antemortem. Constrictive pericarditis as a late complication of idiopathic hypereosinophilic syndrome is discussed.

Endomyocardial disease in South America--report on 23 cases in Venezuela

Twenty-three cases of endomyocardial disease (ED) are presented, studied in Venezuela, a tropical country in northern South America. The diagnosis was confirmed in 18 cases by means of pathological studies, and in 5 cases by angiocardiography which showed the characteristic obliterative ventricular lesions. Eosinophilia was present in 35% of the patients. The most frequent clinical feature was heart failure associated with mitral regurgitation. Systemic embolism was the first clinical feature in 5 cases. In 2 cases, ED was associated with autoimmune haemolytic anaemia or vasculitis. Necropsy revealed a predominance of the left-sided (9/16 cases) and biventricular (6/16 cases) types. The pathological lesions were characterised by fibrous thickening of the endocardium at the apex and the ventricular inflow tracts extending to the myocardium and involving the atrioventricular valves. ED is frequently misdiagnosed as rheumatic valvular cardiopathy. The two-dimensional echocardiogram is a very useful procedure for determining the spatial anatomy of ED. The echo findings were closely correlated with ventriculographic and necropsy findings. Even though ED is widely spread around the world, it is most frequently found in tropical and subtropical countries in Africa, Asia and America, such as Venezuela and Brazil. This suggests that there are aetiological factors in these latitudes, about which little is known.

The role of two-dimensional echocardiography in the detection of potentially embolic intracardiac masses in patients with cerebral ischaemia

The M-mode and two dimensional echocardiographic data of 62 consecutive cardiac patients referred from neurology centres were analysed retrospectively to establish the use of these techniques in detecting underlying cardiac pathology. All patients had presented initially to a neurologist with transient or permanent focal cerebral or retinal ischaemia, and had been referred for cardiac assessment after neurological investigations failed to establish the underlying cause of the neurological event. Patients were divided into two groups. In 30 patients the referring neurologist had found no evidence of cardiac disease (Group I); in the other 32 patients either heart disease or an arrhythmia had been diagnosed prior to cardiac referral (Group II). One of the patients in Group I had echocardiographic evidence of mitral valve prolapse not detected by the neurologist prior to referral; no cardiac pathology was recognised in the other 29 patients in this group. In seven of the 32 (22%) patients from Group II, a cardiac mass presumed responsible for the neurological manifestations was demonstrated echocardiographically, and in six of these histological confirmation was obtained following surgery or at necropsy. Two dimensional echocardiography was the only investigation which visualised the intracardiac pathology in four patients. In the remaining three patients, valve vegetations (two cases) and an atrial tumour (one case) were demonstrated by both echocardiographic methods. In patients with either clinical evidence of cardiac disease or an arrhythmia who have experienced one or more episodes of cerebral or retinal ischaemia, the presence of an intracardiac mass is not uncommon. Two dimensional echocardiography was the method of choice for detecting cardiac thrombus but the use of both methods of ultrasound should be considered as complementary techniques in the investigation of these cases. Routine echocardiography is unlikely to be of value in screening patients who have had a cerebrovascular event and who do not have clinical evidence of heart disease or an arrhythmia.

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.