Churg-Strauss syndrome complicated by eosinophilic endomyocarditis

The Diagnostic Challenge of Eosinophilic Granulomatosis With Polyangiitis Presenting as Acute Eosinophilic Myocarditis: Case Report and Literature Review

Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic vasculitis involving small-to-medium-sized vessels characterized by asthma, vasculitis, and peripheral eosinophilia. EGPA-associated eosinophilic myocarditis (EM) occurs rarely, yet can be fatal if left untreated. Moreover, the accurate diagnosis of EGPA-associated EM without vasculitis is exceptionally difficult because of the overlapping features with EM of other causes. We report a case of probable EGPA with subclinical neurological involvement that presented with acute EM. The constellation of peripheral eosinophilia, left ventricular dysfunction, and normal epicardial coronary arteries raised suspicion of acute EM, which was confirmed by cardiac magnetic resonance (CMR) investigation and endomyocardial biopsy (EMB). Prompt systemic administration of corticosteroids completely restored and normalized myocardial structure and function. Although the patient's history suggested the presumed hypersensitivity myocarditis, EMB revealed EM without vasculitis, not hypersensitivity, leading to a tentative diagnosis of idiopathic hypereosinophilic syndrome. Interestingly, the characteristic findings of vasculitis on CMR imaging strongly suggested EGPA-associated EM. Although the patient had no clinical neurological manifestations, a nerve conduction study confirmed mononeuritis multiplex, leading to the final diagnosis of probable EGPA. Therefore, this case highlights the diagnostic challenge associated with EGPA and the diagnostic synergy of CMR and EMB for an exploratory diagnosis of EGPA-associated EM.

Cardiac involvement in eosinophilic granulomatosis with polyangiitis (formerly Churg-Strauss syndrome): Prospective evaluation at a tertiary referral centre

BACKGROUND

Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare systemic vasculitis. Cardiac specific involvement (CSI) is caused by coronary artery vasculitis, but also by myocardial eosinophilic infiltration. To date, the prevalence of CSI associated with EGPA is unresolved. Aim of this study was to systematically assess the prevalence and clinical impact of CSI in a consecutive outpatient EGPA population.

METHODS

Between October 2018 and July 2019, we prospectively enrolled 52 consecutive EGPA patients. All underwent comprehensive evaluation including a standardized questionnaire, physical examination, 12-lead-ECG, echocardiography. Cardiac magnetic resonance and 24 h-Holter were performed as deemed clinically appropriate. Cardiac abnormalities were defined as CSI based on the likelihood of their relation to EGPA vasculitis, after exclusion of alternative diagnoses.

RESULTS

52 enrolled patients, mean age 59±1 years. Thirteen of the 52 patients (25%) were classified as CSI+. CSI was characterized by myocarditis in four patients, non-scar-related regional wall motions abnormalities (RWMA) in three, apical thrombosis in two (one also had RWMA), pericarditis in three and non-atherosclerotic coronary disease (Prinzmetal angina and coronaritis) in 2. Five (38%) of the 13 CSI+ patients, presented an apical aneurysm. Peak eosinophil count at diagnosis was higher in CSI+: 8000 /μl vs CSI-: 3000 /μl, p = 0.017. Overall, 2 patients had severe LV dysfunction, 5 required urgent hospitalization and 8 required long-term cardioactive therapy.

CONCLUSIONS

CSI was present in one-quarter of patients, often associated with high peak eosinophils. Myocarditis, RWMA and apical aneurysms were the most common manifestations. Although rarely severe and life-threatening, CSI often required long-term cardioactive treatment.

Severe mitral stenosis secondary to eosinophilic granulomatosis resolving after pharmacological treatment

We present a case of 44-year-old woman who underwent effective pharmacological treatment of severe mitral stenosis. The patient was hospitalized due to rapidly progressive dyspnea. Her medical history included asthma, perennial rhinitis, and nasal polyps. Echocardiography showed a mass of the left ventricle involving the mitral valve; cardiac MRI suggested acute endocarditis. Severe peripheral blood eosinophilia was found. Eosinophilic granulomatosis with polyangiitis was diagnosed; treatment with prednisone and cyclophosphamide was started. Despite the clinical improvement, severe mitral stenosis persisted, surgical treatment was planned. However, evaluation after 6 cycles of cyclophosphamide pulse therapy revealed a significant regression of the valvular disease.

Churg-Strauss vasculitis presenting with steroid-responsive left ventricular cardiac mass

A 35-year-old black Saudi man, with a known case of bronchial asthma and allergic rhinitis since childhood, presented with joint pain and swelling, orthopnoea, paroxysmal nocturnal dyspnoea and lower extremity oedema. On examination, we found jugular venous distension, bilateral basal crepitation, wheezing and diffuse synovitis. Investigations were notable for peripheral blood eosinophilia, pericardial effusion and elongated structure in the left ventricular outflow tract on echocardiography, mediastinal and hilar lymphadenopathy and right upper lobe infiltrate on high-resolution CT scan. Pulmonary infiltrate biopsy confirmed eosinophilic vasculitis. Intracardiac mass resolved shortly after pulse steroids indicating an inflammatory mass.

Eosinophilic Granulomatosis with Polyangiitis (EGPA) with an Unusual Manifestation of Mid-Ventricular Obstruction Caused by Endocardial Thrombus

Patient: Male, 46

Final Diagnosis: Eosinophilic granulomatosis with polyangiitis

Symptoms: Chest pain

Medication: —

Clinical Procedure: Skin biopsy

Specialty: Cardiology

Recurrence of eosinophilic granulomatosis with polyangitis after orthotopic heart transplant

Eosinophilic granulomatosis with polyangitis (EGPA), previously referred to as Churg-Strauss syndrome, is a necrotizing small vessel vasculitis associated with eosinophilic infiltrates and extravascular granulomas. We report a case of a Caucasian woman successfully bridged to heart transplantation with a continuous flow left ventricular assist device (LVAD) who survived recurrence of EGPA in the allograft.

A Cardiac Graft from a Donor with Granulomatosis with Polyangiitis-A Case Report

Organ shortage unavoidably leads to shifting strategies in modern transplantation medicine. Experiences with specific comorbidities in terms of organ transplantation therefore have to be made. We report a case of a 51-year-old male patient with successful orthotopic heart transplantation from a donor with granulomatosis with polyangiitis. After a good recovery, the patient was discharged to rehabilitation 2 months after transplantation.

Churg-Strauss syndrome presenting with eosinophilic myocarditis: a diagnostic challenge

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.

Eosinophilic lung diseases

Accurate diagnosis of eosinophilic lung diseases is essential to optimizing patient outcomes, but remains challenging. Signs and symptoms frequently overlap among the disorders, and because these disorders are infrequent, expertise is difficult to acquire. Still, these disorders are not rare, and most clinicians periodically encounter patients with one or more of the eosinophilic lung diseases and need to understand how to recognize, diagnose, and manage these diseases. This review focuses on the clinical features, general diagnostic workup, and management of the eosinophilic lung diseases.

Clinical features and outcomes of eosinophilic myocarditis patients treated with prednisolone at a single institution over a 27-year period

BACKGROUND

Eosinophilic myocarditis is a rare clinical entity characterized by eosinophilia and myocardial inflammation with infiltrating eosinophils. The prognosis of patients with eosinophilic myocarditis is difficult to determine due the disease's rarity and varied causes; consequently, standard treatment has not been established.

OBJECTIVE

To elucidate the clinical characteristics and treatment outcome of eosinophilic myocarditis, we retrospectively studied 7 patients fulfilling the criteria of the Japanese Circulation Society for eosinophilic myocarditis from among 64 patients admitted to our institution with eosinophilia over a 27-year period.

RESULTS

The patients' ages at diagnosis ranged from 36 to 83 years (median: 52 years). The etiologies of the eosinophilic myocarditis were found to be idiopathic (3 patients), Churg-Strauss syndrome (2 patients), parasitic infection (1 patient) and chronic eosinophilic leukemia (CEL) (1 patient). In addition to treatment for the underlying disease, we also administered prednisolone at a dose appropriate to the disease severity (6 of 7 patients). The patient who was diagnosed with a parasitic infection was treated only with albendazole, because eosinophilic myocarditis was mild. The patient with CEL was positive for the FIP1 L1-PDGFRα fusion gene and was treated with imatinib. Eosinophilic cationic protein was a useful marker for assessing disease activity and treatment efficacy. At the end of the study, of the seven patients treated, six were alive (86%), giving a mean survival time of 37 ± 40 months (mean ± SD).

CONCLUSION

Because eosinophilic myocarditis has various etiologies, it is essential to identify the etiology of the underlying disease. In the majority of eosinophilic myocarditis patients, administration of prednisolone may be an effective therapeutic modality producing a good outcome.

Churg-strauss syndrome presenting with cardiac mass and right ventricular obstruction

A 57-year-old woman presenting with asthma, hypereosinophilia, and generalized unspecific symptoms was diagnosed with Churg-Strauss syndrome. Echocardiography revealed a cardiac mass obliterating the right ventricle and severely impaired left ventricular function, which were caused by endomyocardial fibrosis. Cortisone and cyclophosphamide therapy resulted in amelioration of left ventricular function and significant size reduction of the right ventricular mass.

Involvement of the heart by small and medium vessel vasculitis

PURPOSE OF REVIEW

The heart may be involved in many different ways by the systemic vasculitides. In this review, we focus on recently described diagnostic and therapeutic issues in small and medium vessel vasculitis of the heart.

RECENT FINDINGS

Data have emerged on the prevalence and significance of cardiac involvement in the systemic vasculitides. There is an increasing array of sophisticated imaging modalities including echocardiography, PET, and cardiac MRI that aid in the clinical diagnosis.

SUMMARY

Most small and medium vessel vasculitides may involve the heart; however, the mode and incidence of cardiac involvement vary with the different vasculitic syndromes. This review describes the various cardiac manifestations of small and medium vessel vasculitis and the advantages of modern imaging modalities including echocardiography, MRI, and PET coupled with biologic biomarkers such as brain natriuretic peptide and antineutrophilic cytoplasmic antibodies in the diagnosis and management of disease.

Churg-Strauss syndrome revealed by granulomatous acute pericarditis: two case reports and a review of the literature

BACKGROUND

Churg-Strauss syndrome (CSS) is a necrotizing systemic vasculitis with extravascular granulomas and eosinophilic infiltrates of small vessels. CSS is usually revealed by nonspecific signs of necrotizing vasculitis in a context of late-onset asthma and blood eosinophilia. It is considered a systemic vasculitis with the highest prevalence of cardiac involvement and can lead to rapid-onset heart failure due to specific cardiomyopathy. Pericardial effusion may also occur during CSS and is usually well tolerated.

OBJECTIVE

The objective of these case reports was to indicate that CSS may present as tamponade, with or without other visceral involvement.

METHODS

Among CSS patients treated during the past 10 years at 2 French university hospitals, we have identified and described 2 cases revealed by tamponade with pericardial biopsy-proven granulomatous vasculitis. We have also reviewed the international medical literature in PubMed on cardiac involvement in CSS.

RESULTS

The first case report describes a 66-year-old man who had an isolated cardiac tamponade with both inflammatory syndrome and eosinophilia. Long-term remission was obtained with corticosteroids. The second case report describes a 46-year-old woman whose CSS presented with tamponade and associated central nervous system and myocardial involvement. Remission was obtained with corticosteroids and cyclophosphamide. In both cases, CSS was assessed by histological analysis of a pericardial sample.

CONCLUSIONS

CSS may present as isolated cardiac tamponade. Whereas pericarditis with myocardial injury warrants immunosuppressive therapy, isolated pericarditis without other visceral involvement of poor prognosis only requires corticosteroid therapy.

Churg-Strauss syndrome and congenital factor Leiden thrombophilia as nontypical causes of intracardiac thrombosis

We present and discuss the case of a 26-year-old man suffering from Churg-Strauss syndrome (CSS). In our patient the disease severely affected both the heart and the lungs. Left ventricular dysfunction and intracardiac thrombosis, probably secondary to the cardiotoxic effect of eosinophils, were revealed by echocardiography. The risk of thrombosis was additionally increased by the coexistence of the factor V Leiden gene mutation. An opportunely established diagnosis allowed institution of an appropriate pharmacotherapy and subsequently to obtain a significant abatement of the clinical symptoms as well as the laboratory manifestations of the disease.

Sudden death in a neonate with idiopathic eosinophilic endomyocarditis

A 26-day-old male infant who had been fussy and feeding poorly for a period of several hours died suddenly despite efforts at resuscitation. Postmortem examination revealed eosinophilic endomyocarditis unassociated with disease in other organs. The etiology remained unexplained after review of the medical and family histories and circumstances of death, extensive light and immunofluorescence microscopies, and microbiological, metabolic, and toxicologic testing. This appears to be the youngest reported case of eosinophilic endomyocarditis, a disorder that typically occurs in middle-age males and is often associated with benign or malignant hypereosinophilic conditions. The medical literature is reviewed.

Síndrome de Churg-Strauss

A síndrome de Churg-Strauss caracteriza-se por asma, eosinofilia e graus variados de vasculite sistêmica. As formas mais graves com acometimento cardíaco, gastrintestinal, sistema nervoso central e renal requerem ciclofosfamida para seu tratamento.

Churg-Strauss syndrome: clinical presentation, antineutrophil cytoplasmic antibodies, and leukotriene receptor antagonists

PURPOSE

To determine the association of antineutrophil cytoplasmic antibodies (ANCA) and leukotriene receptor antagonists with disease activity in a large series of patients with Churg-Strauss syndrome.

METHODS

Potential subjects were identified by a computerized search of the Mayo Clinic Rochester database for the years 1990 to 2000. Patients meeting one of three classification schemes for Churg-Strauss syndrome were included.

RESULTS

Ninety-one patients met the inclusion criteria. Clinical manifestations were similar to those in previous reports. Mortality was similar to that in the general population. ANCA testing was performed in 74 patients. Seventy-three percent (n = 22) of the 30 patients tested before therapy were ANCA positive, as were 75% (n = 12) of the 16 patients tested during a disease flare. In comparison, 16% (n = 8) of the 49 tested during remission were ANCA positive. Serial measurements indicated a correlation of ANCA levels with disease activity. Central nervous system involvement was the only clinical manifestation that correlated with ANCA status (P = 0.05). Twenty-three patients received leukotriene receptor antagonists, of whom 16 (70%) began treatment before diagnosis and 6 (27%) began during remission. Two of those treated after diagnosis relapsed. In 1 patient the relation between disease and leukotriene receptor antagonist use could not be determined. Use of leukotriene receptor antagonists did not affect the time between onset of asthma and manifestations of vasculitis, and was not correlated with organ manifestations, except sinus disease.

CONCLUSION

No one classification scheme identified all patients. Churg-Strauss syndrome has a better prognosis than other ANCA-associated vasculitides. ANCA status correlates with disease activity, whereas a pathogenic role for leukotriene receptor antagonists in the development of Churg-Strauss syndrome was not noted.

Asthma associated with worsening leg ulcer: a case of vasculitis in primary care

A 71-year-old black woman was admitted to the hospital with a 2-month history of a nonhealing leg ulcer. Her medical history included diabetes mellitus type 2, congestive heart failure, allergic rhinitis, and asthma. The patient's asthma was labile and steroid-dependent until 2 years before admission, at which time zafirlukast therapy was started. On further questioning, the patient revealed a 6-month history of malaise and a 40-lb weight loss. A physical examination showed a 2-cm Stage 3 ulcer on the medial aspect of the right ankle with diminished sensation in both feet and left footdrop. Electromyography revealed mononeuritis multiplex. The patient's white blood cell count was 11,100/mm3 with 60% eosinophils. A sural nerve biopsy showed vasculitis consistent with Churg-Strauss syndrome. One week after prednisone therapy was initiated, the patient's foot strength was nearly normal and her eosinophilia had resolved. Although Churg-Strauss syndrome is a rare disorder, in the setting of asthma and multiple disparate signs and symptoms, the broad diagnostic category of serious vasculitic illness should be considered.

Churg-Strauss syndrome

OBJECTIVES

This article discusses the clinical manifestations and treatment protocols of Churg-Strauss syndrome (CSS). A review of the definition, pathophysiology, and prognosis of CSS is included, as well as more recent evidence of the presumed association between antileukotriene antagonists and CSS.

DATA SOURCES

Relevant articles in the medical literature derived from searching the MEDLINE database (1966 to present) with key terms Churg-Strauss syndrome, allergic granulomatosis, and allergic granulomatous angiitis. Sources included review articles, meta-analyses, randomized control trials, case reports, case series, and seminal articles, the majority of which had been published within the past decade.

STUDY SELECTION

Studies that described the clinical manifestations, pathophysiology, etiology, treatment, or prognosis of CSS.

RESULTS

CSS is a systemic vasculitic disorder with multiorgan involvement and diverse presentations.

CONCLUSIONS

Recognition of the multiorgan manifestations of CSS is crucial to clinical management. Whether a causal relationship exists between antileukotriene antagonists and onset of CSS remains unclear.

Eosinophilia and musculoskeletal disease

Eosinophilia is occasionally a feature of rheumatic disease. The differential diagnosis of eosinophilia includes parasitic infection, systemic vasculitides, eosinophilic arthritis, and myopathies, together with the idiopathic hypereosinophilic syndrome and malignancy. Careful evaluation of the patient should enable an accurate diagnosis to be made. Parasitic infection is the commonest cause of eosinophilia worldwide and can cause systemic disease, as illustrated by the report of Sarcocystis myositis in a group of military personnel in Malaysia. A persistent arthropathy associated with eosinophilia, but not with parasitic infection, has been reported from the far East. Drugs may also cause eosinophilia, and there has recently been much discussion of the relation between Churg-Strauss syndrome and the leukotriene antagonist zafirlukast. The present view is that reduction of steroid dose allows unmasking of previously undiagnosed Churg-Strauss syndrome. The idiopathic hypereosinophilic syndrome may represent a lymphoproliferative process; evidence for this comes from the demonstration that many patients have a clonally expanded population of aberrant T cells.