Endomyocardial disease and eosinophilia

Association of the blood eosinophil count with end-organ symptoms

Introduction

Eosinophilia may cause organ dysfunction, but an exact relation between eosinophil blood counts and adverse outcomes has not been described. The aim of the study is to associate in one model both normal and increased blood eosinophil counts to the subsequent development of common conditions in internal medicine, in which eosinophil granulocytes may play a role for the symptoms.

Methods

From the Copenhagen Primary Care Differential Count (CopDiff) Database, we identified 359,950 individuals with at least one differential cell count (DIFF) during 2000–2007. From these, one DIFF was randomly chosen. From the Danish National Patient Register we ascertained organ damage, within four years following the DIFF. Using multivariable logistic regression, odds ratios were calculated and adjusted for previous eosinophilia, sex, age, year, month, CRP and comorbid conditions.

Results

Risks for skin- and respiratory disease were increased from above the median eosinophil count of 0.16 × 10⁹/l and reached a plateau around 1.0 × 10⁹/l. Furthermore, risks of most outcomes also increased when the eosinophil count approached zero.

Conclusions

The observed U-shaped association with a plateau of risks around 1 × 10⁹/l indicates that the risk for symptoms due to eosinophilia do not increase proportionate at higher counts. This study demonstrates for the first time that there is indeed an increased risk below median count of 0.16 × 10⁹/l for an increased risk for the same manifestations. Clinically, it means that a normal or even low count of eosinophils do not rule out a risk for organ affection by eosinophils, and may contribute to explain, why patients may have normal eosinophil counts in e.g. asthma or allergy and still have symptoms from the lungs and skin, most likely explained by the extravasation of eosinophils.

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Blood eosinophilia may cause end-organ symptoms.

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An exact relation between eosinophil count and outcome has not been demonstrated.

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Eosinophil numbers correlate to organ damage even below the definition of eosinophilia.

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This association is U-shaped between organ manifestations and eosinophil count in blood.

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A plateau of risks is observed around 1 × 10⁹/l.

Clinical Characteristics and Treatment of Cardiomyopathies in Children

Cardiomyopathies are diseases of the heart muscle, a term introduced in 1957 to identify a group of myocardial diseases not attributable to coronary artery disease. The definition has since been modified to refer to structural and or functional abnormalities of the myocardium where other known causes of myocardial dysfunction, such as systemic hypertension, valvular disease and ischemic heart disease, have been excluded. In this review, we discuss the pathophysiology, clinical assessment and therapeutic strategies for hypertrophic, dilated and hypertrophic cardiomyopathies, with a particular focus on aspects unique to children.

From an isolated right ventricular thrombus to the diagnosis of the hypereosinophilic syndrome

This case concerns a 58-year-old male who presented with abdominal pain, anorexia, nausea, and exertional dyspnea of one month's duration. On further evaluation peripheral eosinophilia was conspicuous and eosinophilic infiltration was found in the gastrointestinal system and bone marrow. Echocardiography showed an isolated right ventricular thrombus with tricuspid valve involvement. Cardiac magnetic resonance imaging helped to confirm the diagnosis of cardiac involvement in hypereosinophilic syndrome without requiring a cardiac biopsy.

MRI of hypertrophic cardiomyopathy: part 2, Differential diagnosis, risk stratification, and posttreatment MRI appearances

OBJECTIVE

We present a two-part review about the use of MRI in patients with hypertrophic cardiomyopathy (HCM). This article, Part 2, covers the differential diagnosis, risk stratification, and posttreatment MRI follow-up appearances in these patients.

CONCLUSION

Cardiovascular MRI is a useful imaging tool for the diagnosis of HCM and follow-up of patients after either surgical myomectomy or septal ablation therapy. In addition, MRI can help to discriminate HCM from the differential diagnoses of other cardiomyopathies and cardiac disorders, and it can potentially identify the subset of patients at risk of sudden cardiac death.

Atypical presentation of eosinophilic endomyocardial disease

Idiopathic hypereosinophllic syndrome is classically defined as prolonged, unexplained peripheral eosinophilia in a patient presenting with evidence of end-organ damage. The heart is frequently Involved, resulting In eosinophilic endomyocardial disease and eventually restrictive cardlomyopathy. The mortality rate is high because of progressive heart failure or ventricular arrhythmias. We describe a patient who presented with a left ventricular apical thrombus without notable peripheral eosinophilia. Findings from clinical evaluation and extensive diagnostic testing, including right ventricular biopsy, were Inconclusive. Resection of the thrombus and subjacent endomyocardium revealed eosinophilic Infiltration of the endomyocardium, which led to the diagnosis of eosinophilic endomyocardial disease. Clinicians should be aware of the variable presentation of patients with eosinophil-associated endomyocardial disease so that affected patients may benefit from early diagnosis and treatment.

Regressive Aortic Valve and Infundibular Tumors During Idiopathic Hypereosinophilic Syndrome

Fibroblastic endocarditis is a classic complication of prolonged hypereosinophilic syndrome, whatever the cause. In France, it is most frequently encountered in cases of idiopathic hypereosinophilic syndrome. It commonly involves the apex of the ventricles, with a clinical picture of restrictive cardiomyopathy of unfavorable prognosis, and the auriculoventricular valves. We report the case of a 77-year-old man in whom atypical cardiac involvement disclosed idiopathic hypereosinophilic syndrome. In addition to the usual features of obliteration of the apex and restrictive cardiomyopathy, echocardiographic examination showed severe left ventricular dysfunction and intracardiac tumors, one of which was unusually localized to an aortic valve. Treatment, which comprised strict control of the eosinophilic process, standard treatment for cardiac failure, and anticoagulation therapy, produced rapid and long-lasting improvement of his clinical status and left systolic and diastolic ventricular function, and on echocardiography the intracardiac tumors had totally disappeared. The patient suddenly died of septic shock 16 months after first being seen.

[Spectrum of hypereosinophilia syndrome based on 2 clinical case reports]

BACKGROUND

Two severe cases of hypereosinophilic syndrome with cardiopulmonary symptoms, erythema nodosum, eosinophilic ileocolitis and paresthesia are reported. Definition, etiology, pathophysiological mechanisms, types, complications and therapeutic approaches of this relatively rare clinical disorder are discussed on the basis of these two cases. The distinction between eosinophilia and hypereosinophilic syndrome is clearly defined.

DIFFERENTIAL DIAGNOSIS

The 2 cases of hypereosinophilic syndrome demonstrate the difficulty to decide whether they represent the idiopathic or the reactive type of hypereosinophilic syndrome. If the assumption is made in favor of the reactive type of hypereosinophilic syndrome the assumed prognosis could eventually be too promising. In case of an assumed idiopathic type of hypereosinophilic syndrome the search for causing factors like allergens could be left out. The decision concerning the type of hypereosinophilic syndrome of the 2 cases reported was made with high probability. In the case of idiopathic hypereosinophilic syndrome, eosinophilic leukemia was excluded by bone marrow biopsy.

CONCLUSION

In order to be able to make a diagnosis it is necessary to search carefully for causing and influencing factors of the hypereosinophilic syndrome such as allergens or medicaments and to eliminate them. The hypereosinophilic syndrome must be put under frequent control in order to avoid complications or to start with therapeutic approaches in time.

Clonal eosinophilic disorders and the hypereosinophilic syndrome

An increase in the blood eosinophil count may occur in a number of disease states including allergies, parasitic infections, vascular disease and as a reaction to the presence of malignant tumours. This article defines those disorders that are not purely reactive, and describes in detail the diagnosis and features of clonal eosinophilic disorders and the hypereosinophilic syndrome. The clonal disorders that are associated with eosinophilia are discussed, in particular the acute and chronic eosinophilic leukaemias and clonal eosinophilias in association with acute myeloid leukaemia, myeloproliferative disorders and myelodysplastic syndromes. Whether eosinophilia is produced by a clonal or reactive disorder, the end result can often be the same, i.e. end organ damage produced by sustained hypereosinophilia in the presence of eosinophil activation. When no cause for the eosinophilia leading to the end organ damage is found, this disease is termed 'idiopathic hypereosinophilic syndrome'. Its pathogenesis, clinical features and management are discussed with particular reference to the possibility of it being a T-cell-associated disorder.

Chronic myeloid leukemia associated hypereosinophilic syndrome with a clonal t(4;7)(q11;q32)

Patients with chronic myeloid leukemia (CML) show the Philadelphia (Ph) translocation in more than 95% of the cases. The remaining cases, without the cytogenetic or molecular equivalent of the BCR-ABL rearrangement, are "Philadelphia negative" and may have alternate chromosomal aberrations. Ph negative CML patients are known to have a poor prognosis. We report on a young patient with a hypereosinophilic syndrome in the presence of a clonal translocation t(4;7) with a peripheral leukocytosis, a severe thrombocytopenia, and anemia at first presentation, who developed bone marrow changes typical of CML. Bone marrow function and hypereosinophilia improved only partially and temporarily under therapy. The patient died 10 months after diagnosis of diffuse leukemic embolism and organ infiltration resulting in paraplegia. The case demonstrates that beside "idiopathic" hypereosinophilic syndromes (HES), a proportion of such patients suffer from eosinophilic leukemias. In these cases, karyotype analysis may help to distinguish these states by the identification of clonal chromosomal abnormalities. A karyotype anomaly hitherto not reported can be added to the list of aberrations in hypereosinophilic states associated with myeloproliferative processes.