Interleukin-5 Antagonist Monoclonal Antibody Therapy Improves Symptoms and Reduces Steroid Dependence in Eosinophilic Myocarditis Patients

Eosinophilic myocarditis (EM) is a rare disease associated with significant morbidity and mortality. This case series follows the clinical courses of 3 patients with EM. The use of mepolizumab, an anti-interleukin-5 monoclonal antibody, as an adjunctive treatment was associated with stabilization of cardiac function and improved long-term outcomes.

Cardiac Magnetic Resonance Imaging Used to Determine a Rare Etiology of a Layered Left Ventricular Apical Thrombus

Eosinophilic myocarditis (EM) is a rare disease, often associated with hypereosinophilic syndrome (HES). Historically, the diagnostic gold standard was endomyocardial biopsy (EMB). We present a unique case of a 58-year-old female who presents after a syncopal episode and was found to have a layered left ventricular (LV) thrombus. Using laboratory studies and cardiac magnetic resonance imaging (MRI), we were able to delineate the etiology, avoiding any invasive testing.

Cardiac involvement in eosinophilic granulomatosis with polyangiitis: acute eosinophilic myocarditis and chronic inflammatory cardiomyopathy

OBJECTIVES

Currently, cardiac involvement is used to describe all eosinophilic granulomatosis with polyangiitis (EGPA) cardiac problems. However, heterogeneity exists among them. We aimed to depict the disease spectrum of EGPA cardiac involvement and identify high-risk population.

METHODS

We included EGPA patients hospitalized in our center from 2012 to 2023 and in public databases. Based on the cardiac enzymes, cardiac magnetic resonance imaging, and endomyocardial biopsy results, the patients were divided into 3 groups: eosinophilic myocarditis (EGPA-EM), chronic inflammatory cardiomyopathy (EGPA-ICM) and EGPA-Control. Their clinical, laboratory, imaging results and prognoses were collected and compared.

RESULTS

A total of 193 EGPA patients were included, 118 with cardiac involvement (74 EGPA-EM, 44 EGPA-ICM) and 75 control. Among EGPA-control, EGPA-ICM and EGPA-EM, eosinophil increased (6.12/8.71/10.42 × 109/l, p< 0.01), ANCA positivity decreased (41.33/31.82/14.86%, p< 0.01), and lung involvement reduced (73.33/72.73/43.24%, p= 0.02). In EGPA-EM, cardiac troponin further elevated (0.27 vs 6.00 ng/ml, p< 0.01), ejection fractions decreased (57.79 vs 33.20%, p< 0.01), while more ST-T abnormality was observed (41.89 vs 20.45%, p= 0.02). The prognosis of EGPA-EM was significantly worse, with 14.86% death rate, and 2-year event-free survival rate below 50%. Further, we proposed a LATE-EAST diagnostic score (7 items, 9 points) to discriminate EGPA-EM from EGPA-ICM using 4 points as threshold [AUC 0.85 (95%CI 0.78-0.92), sensitivity 0.78, specificity 0.86].

CONCLUSIONS

We first proposed different subtypes of cardiac involvement in EGPA. Identification and treatment of EGPA-EM needs improvement. LATE-EAST score could recognize the high-risk EGPA-EM effectively. Multi-disciplinary treatment is warranted, immunosuppressive therapy should be given timely and anti-IL-5 antibodies be tested in trials.

The portrait of a stranger: the hypereosinophilic syndrome with cardiac involvement

INTRODUCTION

Hypereosinophilic syndrome is a rare clinical condition, and cardiac involvement confers a poor prognosis. Hypereosinophilic myocarditis is a medical emergency and targeted treatment should be started promptly even before a definitive diagnosis could be made.

CASE PRESENTATION

A 27-year-old female patient is hospitalized for exertional dyspnea, chest pain, and fatigue for the past 2 weeks. She also describes left leg paresthesias. Clinical examination was in normal limits. ECG showed sinus tachycardia, QS pattern in V1-V4, and diffuse flattened T waves. Laboratory tests revealed increased inflammatory markers, hypereosinophilia, elevated cardiac enzymes, high NT-proBNP. Echocardiography revealed LV dysfunction (EF 31%), while cardiac MRI showed diffuse delayed enhancement with predominant subendocardial disposition. The electromyogram was suggestive of left tibial nerve neuropathy. We interpreted the case as eosinophilic myocarditis with an urgent requirement of therapy and initiated high-dose glucocorticoid therapy and the GDMT 4-pillar heart failure treatment. We excluded common infectious, myeloproliferative syndromes, and frequent associated autoimmune diseases. With prednisone, the eosinophil count rapidly normalized and we gradually tapered the dose by 5 mg per week, however continuing with heart failure therapy. At monthly follow-up visits, there was a significant clinical improvement, with normalization of the eosinophilic count, and a near-normalization of myocardial function. The only symptom that persisted was paresthesias linked to left tibial neuropathy.

CONCLUSION

The surprisingly rapid and favorable course of the disease offers a high index of suspicion for a toxic or a reactive transitory etiology, however still unidentified. In our case, the cause of eosinophilia remained unknown, although we managed to narrow down the possible etiologies. A surprisingly good clinical response was obtained with non-specific treatment targeting mainly hyperosinophilic myocarditis.

Myocarditis Presenting as ST-Elevation Myocardial Infarction

When evaluating a patient with ST-segment elevation on ECG and acute chest pain, providers often rapidly arrive at the diagnosis of ST-elevation myocardial infarction (STEMI). As myocardial infarction is deadly and time is of the essence in establishing reperfusion, it is reasonable to place it at the top of the differential. However, doing so should not come at the expense of conducting a thorough clinical evaluation, considering all causes of ST-segment elevation, and creating a comprehensive differential. Myocarditis, in particular, can present similarly to myocardial infarction and misdiagnosis can lead to unnecessary and sometimes harmful interventions such as thrombolytic therapy, vasodilator therapy, or coronary angiography. We present a case of myocarditis mimicking STEMI and discuss diagnosis and treatment of myocarditis.

Hypereosinophilic Syndrome Endocarditis With Severe Biventricular Failure Complicated by Sepsis: A Challenging Case

Hypereosinophilic syndrome (HES) is a myeloproliferative disorder characterized by persistent hypereosinophilia that is associated with multi-organ damage. Eosinophilic endocarditis is a serious complication of HES. The exact prevalence of the disease is unknown, and it is characterized by a persistently elevated eosinophil count, resulting in multi-organ involvement due to eosinophilic infiltration. We present a case of a 65-year-old Caucasian male patient who presented with one-week symptoms of feeling unwell and intermittent pleuritic chest pain. His medical history was significant for the idiopathic hypereosinophilic syndrome, eosinophilic myocarditis, hypertension (HTN), type 2 diabetes mellitus (T2DM), and chronic obstructive pulmonary disease (COPD). Inflammatory markers were raised, including eosinophil count, and a transthoracic echocardiogram (TTE) showed a mass attached to the mitral valve (MV) leaflets, suggesting vegetation or thrombus. The patient was commenced on intravenous antibiotics, inotropes for septic shock, and low molecular weight heparin (LMWH) for a possible thrombus. He showed mild biochemical improvement initially without any clinical improvement before further deterioration secondary to aspiration pneumonia. He was seen by the palliative care team and mental health team for confusion and agitation and was put on the palliative care pathway. All active medical treatment was stopped, and the patient succumbed to his illness three weeks into his admission.

FIP1L1-PDGFRA Clonal Hypereosinophilic Syndrome With Eosinophilic Myocarditis and Intracardiac Thrombus

A 45-year-old man from El Salvador with no past medical history presented with cough and chest pain. Investigations revealed 60% peripheral eosinophilia (absolute count 12.3 K/uL). Cardiac imaging was consistent with myocarditis with intracardiac thrombus formation. Endomyocardial biopsy confirmed eosinophilic infiltration of the myocardium, and bone marrow biopsy showed hypercellular marrow with 28% eosinophils. Cytogenetics/fluorescence in situ hybridization (FISH) confirmed positive FIP1L1-PDGFRA rearrangement. The patient was treated for FIP1L1-PDGFRA clonal hypereosinophilic syndrome with associated eosinophilic myocarditis and intracardiac thrombus. The treatment regimen consisted of a steroid taper, imatinib, and anticoagulation. Treatment was followed by normalization of the eosinophil count. At two-year follow-up, the patient was without recurrence of eosinophilia on maintenance imatinib and indefinite anticoagulation with warfarin.

Pericardial Effusion and Progressive Bilateral Effusion as Rare Presentations of Idiopathic Hypereosinophilic Syndrome

Hypereosinophilic syndrome (HES) is a rare disease with peripheral blood eosinophils >1500/µL and end-organ damage. We encountered a case of idiopathic HES in a woman in her 60s who presented with dyspnea due to cardiac effusion and bilateral pleural effusions. At first, the patient did not have eosinophilia in the peripheral blood, and the presence of serum pericardial fluid and pleural effusion led to suspicion of carcinomatous pericarditis and pleurisy. One month later after onset, eosinophilia in the peripheral blood was observed, and HES was suspected for the first time. However, inflammatory cell infiltration by eosinophils has been observed in the pleural fluid specimen before eosinophilia in the peripheral blood. Prednisolone was administered, and the pleural effusion and respiratory failure quickly abated. This case provided an educational illustration of a unique manifestation of cardiac tamponade and HES, characterized by the absence of peripheral blood eosinophilia at the initial presentation.

Cardiomegaly and Low Voltage Suggest Cardiac Involvement in a Patient With Hypereosinophilic Syndrome: A Case Report

Hypereosinophilic syndrome is a heterogeneous group of disorders, the majority of which are idiopathic. Cardiac manifestations, particularly eosinophilic myocarditis and endomyocardial fibrosis, are a typical course of morbidity and mortality in hypereosinophilic syndrome. We present a case of a patient with asthma and idiopathic eosinophilia who presented with dyspnea and edema. Cardiac ultrasonography showed pericardial effusion and reduced left ventricular motion, which persisted despite heart failure therapy, although pulmonary congestion improved. The peripheral blood eosinophil count was markedly elevated four days after admission, even though eosinophilia was not present at admission. Parasitic disease, autoimmune disease, and drug-induced cardiomyopathy were excluded as possibilities. A high dose of steroid therapy was started due to eosinophilic myocarditis. Cardiac function improved soon after therapy, along with a reduction in eosinophils. Upon retrospective examination, cardiomegaly and low voltage were observed, along with an elevation in the eosinophil count 15 months before admission. Monitoring chest radiography and electrocardiograms according to fluctuations in eosinophils may enable early detection and treatment of cardiac involvement in patients with hypereosinophilic syndrome, as demonstrated by this case.

Eosinophilic Granulomatosis with Polyangiitis in an 8-year-old Girl Manifesting as Hypereosinophilic Syndrome with Myocarditis, Stroke, and Subsequent Orbital Involvement

Hypereosinophilic syndrome (HES) is a heterogeneous group of disorders characterized by peripheral blood eosinophilia of 1.5 × 109/L (1,500/μL) or greater, with evidence of end-organ damage attributable to eosinophilia (e.g., heart, liver or lung) with no other cause for the end-organ damage [1]. Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare disorder that may affect multiple organ systems (lungs, heart, kidneys, or the nervous system). The disorder is characterized by hypereosinophilia in the blood and tissues, inflammation of blood vessels (vasculitis), and the development of inflammatory nodular lesions called granulomatosis [2]. We report a case with a 9-year-old girl presenting with severe hypereosinophilia, ischemic stroke, right-sided hemiparesis and myocarditis treated with methylprednisolone, enoxaparin, rivaroxaban and carvedilol. The patient recovered successfully from myocarditis and stroke but manifested with right-sided orbital involvement as pre- and post-septal orbital cellulitis 10 months later with necrotizing granulomatous perivascular chronic infiltration with eosinophilic infiltration treated with methylprednisolone and subsequent mepolizumab with successful remission of orbital involvement, but severe exogenous Cushing's syndrome and myocardial fibrosis.

Case report of eosinophilic granulomatosis with polyangitis presenting as acute myocarditis

This case presents a challenging diagnosis of EGPA presenting as eosinophilic myocarditis. It is a condition that can mimic many other diseases and where prompt diagnosis and early treatment is essential for recovery. The diagnosis was made after an endomyocardial biopsy (EMB) and showed the importance of EMB in the diagnostic work-up.

Hypersensitivity Myocarditis after COVID-19 mRNA Vaccination

Background: Myocarditis, even in a severe and lethal form, may occur after COVID-19 mRNA (BNT162b2) vaccination. However, its pathway, morphomolecular characterization and treatment are still unknown. Methods: Routine hematochemical screening, ECG, Holter monitoring, 2D echocardiogram cardiac magnetic resonance (CMR) and invasive cardiac studies (cardiac catheterization, selective coronary angiography, left ventriculography and left ventricular endomyocardial biopsy) are reported from three patients (39F-pt1, 78M-pt2, 52M-pt3) with severe compromise of conduction tissue (junctional rhythm and syncope, pt1) or cardiac function compromise (LVEF ≤ 35%, pt2 and pt3) after COVID-19 mRNA (BNT162b2). Results: Hematochemical data and coronary angiography were normal in the patients studied. Histology showed in all three patients extensive myocardial infiltration of degranulated eosinophils and elevation of serum cationic protein directly responsible for cardiomyocyte damage. These findings demonstrate myocarditis hypersensitivity to some component of the vaccine (spike protein?) acting as a hapten to some macromolecules of cardiomyocytes. Steroid administration (prednisone, 1 mg/kg die for 3 days, followed by 0.33 mg/kg for 4 weeks) was followed by complete recovery of cardiac contractility in pt2 and pt3. Conclusions: Eosinophilic myocarditis is a possible adverse reaction to the mRNA COVID-19 vaccine. Its pathway is mediated by release of cationic protein and responds to short courses of steroid administration.

Immunomodulating Therapies in Acute Myocarditis and Recurrent/Acute Pericarditis

The field of inflammatory disease of the heart or "cardio-immunology" is rapidly evolving due to the wider use of non-invasive diagnostic tools able to detect and monitor myocardial inflammation. In acute myocarditis, recent data on the use of immunomodulating therapies have been reported both in the setting of systemic autoimmune disorders and in the setting of isolated forms, especially in patients with specific histology (e.g., eosinophilic myocarditis) or with an arrhythmicburden. A role for immunosuppressive therapies has been also shown in severe cases of coronavirus disease 2019 (COVID-19), a condition that can be associated with cardiac injury and acute myocarditis. Furthermore, ongoing clinical trials are assessing the role of high dosage methylprednisolone in the context of acute myocarditis complicated by heart failure or fulminant presentation or the role of anakinra to treat patients with acute myocarditis excluding patients with hemodynamically unstable conditions. In addition, the explosion of immune-mediated therapies in oncology has introduced new pathophysiological entities, such as immune-checkpoint inhibitor-associated myocarditis and new basic research models to understand the interaction between the cardiac and immune systems. Here we provide a broad overview of evolving areas in cardio-immunology. We summarize the use of new imaging tools in combination with endomyocardial biopsy and laboratory parameters such as high sensitivity troponin to monitor the response to immunomodulating therapies based on recent evidence and clinical experience. Concerning pericarditis, the normal composition of pericardial fluid has been recently elucidated, allowing to assess the actual presence of inflammation; indeed, normal pericardial fluid is rich in nucleated cells, protein, albumin, LDH, at levels consistent with inflammatory exudates in other biological fluids. Importantly, recent findings showed how innate immunity plays a pivotal role in the pathogenesis of recurrent pericarditis with raised C-reactive protein, with inflammasome and IL-1 overproduction as drivers for systemic inflammatory response. In the era of tailored medicine, anti-IL-1 agents such as anakinra and rilonacept have been demonstrated highly effective in patients with recurrent pericarditis associated with an inflammatory phenotype.

A Progressive Case of Eosinophilic Myocarditis Due to Eosinophilic Granulomatosis With Polyangiitis in a Caucasian Male

Vasculitis is an inflammatory process involving blood vessels of various sizes, including the small vessels in the kidneys to the large vessels, such as the aorta. This inflammatory condition is usually autoimmune in nature and is associated with involvement of many locations, such as the sinuses, lungs, kidneys, and even the heart. Specifically, eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic vasculitis that may initially hide as asthma, allergic rhinitis, and/or sinusitis. However, it is known to become a lethal disease once progressed to include cardiovascular manifestations. It is important to remember EGPA as a differential for any patient with a history of asthma, allergic rhinitis, and/or sinusitis who also presents with cardiovascular complaints and eosinophilia. Treatment recommendations focus on immunosuppression in such cases. In this article, we discuss the case of a 62-year-old male, with a known history of asthma, who presented to the emergency department with concern for his chest pain and right-sided weakness. He was later diagnosed with EGPA with eosinophilic myocarditis. Diagnosis and treatment are described.

Myocarditis Presenting as Sudden Death in Infants and Children: A Single Centre Analysis by ESGFOR Study Group

BACKGROUND

Acute myocarditis is an inflammatory disease of the heart mostly diagnosed in young people, which can present as sudden death. The etiology includes infectious agents (mostly viruses), systemic diseases and toxins. We aim to characterize infants and children with myocarditis at post-mortem presenting as sudden deaths.

METHODS

Retrospective evaluation of 813 post-mortems in infants and children dying suddenly and unexpectedly between 2009-2019. Data retrieved included histological features, microbiology and clinical history.

RESULTS

23 of 813 post-mortems reviewed corresponded to acute myocarditis and 1 to dilated cardiomyopathy related to remote Parvovirus infection. PCR identified enterovirus (7), parvovirus (7 cases, 2 also with HHV6 and 1 case with EVB), Influenza A (1), Parainfluenza type 3 (1). Two cases corresponded to hypersensitivity myocarditis, 1 was Group A Streptococcus and 5 idiopathic myocarditis. Enterovirus was frequent in infants (7/10), and in newborns was associated with meningoencephalitis or congenital myocarditis. More than 50% were less than 2 years of age and all remained clinically unsuspected.

CONCLUSION

Myocarditis represents almost 3% of all sudden pediatric deaths. Enterovirus and parvovirus were the most common viruses. This retrospective analysis showed that patients experienced viral symptoms but remained unsuspected, highlighting the need for more clinical awareness of myocarditis.

Fulminant Eosinophilic Myocarditis and VT Storm

Eosinophilic myocarditis is a rare and frequently fatal disease that is often undiagnosed until autopsy. We report a case of eosinophilic myocarditis with an unusual initial presentation of palpitations that subsequently evolved into ventricular tachycardia storm and death within 4 days. (Level of Difficulty: Beginner.).

Follow-up CMR in a case of Loeffler endocarditis

The typical finding of hypereosinophilic syndrome (Eosinophilic myocarditis) in the delayed enhancement (DE) cardiac magnetic resonance (CMR) is the "double V" sign, which includes (a) normal myocardium, (b) thickened enhanced endomyocardial layer, and (c) overlying apical thrombus. Corticosteroids may result in significant improvement of myocardial involvement.

Allergy and the Heart: Eosinophilic Myocarditis With Biventricular Thrombi

A 40-year-old woman with history of atopy and peripheral eosinophilia presented with clinical signs of heart failure. Echocardiography revealed a restrictive cardiomyopathy with biventricular thrombi. Hypereosinophilic syndrome resulting in eosinophilic myocarditis (Loeffler’s syndrome) was diagnosed. This case highlights the workup, diagnosis, and management of hypereosinophilic syndrome with eosinophilic myocarditis. (Level of Difficulty: Advanced.)

Eosinophilic Myocarditis Secondary to T-Cell Lymphoma Complicated by Left Ventricular Thrombus and Tear

We describe a 54-year-old male in whom eosinophilic myocarditis secondary to T-cell lymphoma complicated by bilateral ischemic stroke was diagnosed. The source, identified as an apical tear with thrombus formation, was revealed by transthoracic echocardiography. (Level of Difficulty: Advanced.)

Fatal Eosinophilic Myocarditis in a Healthy 17-Year-Old Male with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2c)

Background: Cardiac damage is frequently referred to in patients with SARS-CoV-2, is usually diagnosed by enzyme elevations, and is generally thought to be due to underlying coronary artery disease. There are references to cardiomyopathies accompanying coronavirus, but there has been no histologic confirmation.Case report: A previously healthy 17 year male old presented in full cardiac arrest to the emergency department after a 2 day history of headache, dizziness, nausea and vomiting. Autopsy demonstrated an enlarged flabby heart with eosinophilic myocarditis. There was no interstitial pneumonia or diffuse alveolar damage. Postmortem nasopharyngeal swabs detected severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) known to cause coronavirus disease 2019 (COVID-19). No other cause for the eosinophilic myocarditis was elucidated.Conclusion: Like other viruses, SARS-CoV-2 may be associated with fulminant myocarditis.

Fulminant Versus Acute Nonfulminant Myocarditis in Patients With Left Ventricular Systolic Dysfunction

BACKGROUND

Fulminant myocarditis (FM) is a form of acute myocarditis characterized by severe left ventricular systolic dysfunction requiring inotropes and/or mechanical circulatory support. A single-center study found that a patient with FM had better outcomes than those with acute nonfulminant myocarditis (NFM) presenting with left ventricular systolic dysfunction, but otherwise hemodynamically stable. This was recently challenged, so disagreement still exists.

OBJECTIVES

This study sought to provide additional evidence on the outcome of FM and to ascertain whether patient stratification based on the main histologic subtypes can provide additional prognostic information.

METHODS

A total of 220 patients (median age 42 years, 46.3% female) with histologically proven acute myocarditis (onset of symptoms <30 days) all presenting with left ventricular systolic dysfunction were included in a retrospective, international registry comprising 16 tertiary hospitals in the United States, Europe, and Japan. The main endpoint was the occurrence of cardiac death or heart transplantation within 60 days from admission and at long-term follow-up.

RESULTS

Patients with FM (n = 165) had significantly higher rates of cardiac death and heart transplantation compared with those with NFM (n = 55), both at 60 days (28.0% vs. 1.8%, p = 0.0001) and at 7-year follow-up (47.7% vs. 10.4%, p < 0.0001). Using Cox multivariate analysis, the histologic subtype emerged as a further variable affecting the outcome in FM patients, with giant cell myocarditis having a significantly worse prognosis compared with eosinophilic and lymphocytic myocarditis. In a subanalysis including only adults with lymphocytic myocarditis, the main endpoints occurred more frequently in FM compared with in NFM both at 60 days (19.5% vs. 0%, p = 0.005) and at 7-year follow up (41.4% vs. 3.1%, p = 0.0004).

CONCLUSIONS

This international registry confirms that patients with FM have higher rates of cardiac death and heart transplantation both in the short- and long-term compared with patients with NFM. Furthermore, we provide evidence that the histologic subtype of FM carries independent prognostic value, highlighting the need for timely endomyocardial biopsy in this condition.

A case of suspected eosinophilic myocarditis recognized by a fully noninvasive approach and safely treated with corticosteroids despite underlying hepatitis C virus-related hepatitis

Hypereosinophilic syndrome can lead to acute myocarditis with a potentially severe systolic dysfunction and serious complications. A 75-year-old patient suffering from Hepatitis C virus (HCV) related-hepatitis came to our observation for idiopatic hypereosinophilic syndrome and acute severe cardiac systolic dysfunction without coronaropathy. Cardiac magnetic resonance showed a 'patchy' subendocardial and intramyocardial late gadolinium enhancement pattern often seen in eosinophilic myocarditis (EM). Assuming EM, appropriate corticosteroid therapy was initiated and it led to clinical remission. Despite endomyocardial biopsy (EMB) is the diagnostic gold standard for EM, in this case only a noninvasive integrated imaging approach was successfully attempted. Given an adequate clinical context, in our opinion EM can be correctly recognized without EMB and so promptly and safely treated with corticosteroids, even when an underling mild HCV-hepatitis is present.

Idiopathic eosinophilic myocarditis presenting with features of an acute coronary syndrome

Summary

A 62-year-old female was admitted with severe left-sided chest pain, nausea and pre-syncope. She had widespread T wave inversion on ECG and elevated troponins and was suspected to have an acute coronary syndrome event. Invasive coronary angiogram revealed normal coronary anatomy with no flow-limiting lesions. Echocardiography and cardiac MRI revealed impaired left ventricular (LV) systolic impairment, a mobile LV apical thrombus and a moderate global pericardial effusion with no significant compromise. Full blood count analysis indicated the patient to have significant eosinophilia, and the patient was diagnosed with idiopathic eosinophilic myocarditis. She was commenced on Prednisolone and Apixaban, and eosinophil levels returned to normal after 10 days of steroids. Over the course of 3 months, the patient had a complete recovery of her LV function and resolution of the LV thrombus. This case highlights a rare, reversible case of idiopathic eosinophilic myocarditis which may present similar to acute coronary syndrome.

Learning points:

Cardiac involvement in hypereosinophilia

Cardiac abnormalities associated with hypereosinophilia represent rare diseases and occurs most commonly due to hypersensitivity or allergic reactions, other possible etiologies cover infections, malignancy, vasculitis or hypereosinophilic syndromes. Three stages of cardiac involvement are usually described. Initially, myocardial inflammation occurs, that can continue with a thrombotic stage and eventually progress to the last irreversible stage called endomyocardial fibrosis, which represents one of the acquired forms of restrictive cardiomyopathy. In most patients, increased levels of eosinophils in the blood differential test; however, it may not be present in the initial stages of the disease. Of the imaging methods, magnetic resonance imaging and positron emission tomography combined with CT PET-CT are used in addition to echocardiography. Endomyocardial biopsy may be indicated for definitive evidence of eosinophilic myocarditis. The clarification of the cause of hypereosinophilia is necessary for specific treatment of this disorder.

Fatal Sarcocystis cruzi-induced eosinophilic myocarditis in a heifer in Uruguay

Sarcocystis spp. are causative agents of bovine eosinophilic myositis and/or myocarditis, which are chronic subclinical myopathies that are occasionally responsible for condemnation at slaughterhouses. Sarcocystis cruzi is a protozoan parasite of worldwide distribution transmitted by canids, most commonly associated with subclinical infection in cattle. Although S. cruzi infections can rarely lead to fatal systemic disease, fatal cardiac cases with confirmation of the etiologic diagnosis have not been reported, to our knowledge. We describe herein an unusual case of S. cruzi-induced fatal bovine eosinophilic myocarditis. A 22-mo-old, Holstein-Hereford heifer, in a group of 110 cattle on pasture, manifested growth retardation and died in February 2017. Autopsy revealed myriad yellow-green 1-3-mm coalescing foci, surrounded by fibrosis, affecting ~75% of the ventricular myocardium. Pulmonary edema, ascites, and hydrothorax were consistent with chronic congestive heart failure. Histology revealed severe eosinophilic, granulomatous, necrotizing myocarditis, with multinucleate giant cells, fibrosis, and mineralization. Numerous thin-walled protozoan cysts resembling Sarcocystis spp. were present in the necrotic foci and within the sarcoplasm of adjacent cardiomyocytes. PCR and sequencing of the 18S rRNA gene revealed 99.9-100% homology with S. cruzi. Sarcocystosis can be a rare cause of fatal myocarditis in cattle.

A Curious Case of Coronary Vasospasm with Cardiogenic Shock: Type 1 Kounis Syndrome Complicated by Eosinophilic Myocarditis

Kounis syndrome is a rare but life-threatening form of coronary vasospasm, defined by the co-occurrence of acute coronary syndrome and hypersensitivity reaction. We present a case of refractory coronary vasospasm with aborted sudden cardiac arrest secondary to type 1 Kounis syndrome, which was complicated by eosinophilic myocarditis and cardiogenic shock. A 29-year-old Hispanic woman with history of vasospastic angina, presented with recurrent episodes of angina at rest. Initial evaluation revealed hyper-eosinophilia, elevated troponin and diffuse ST segment depression on electrocardiogram (ECG). Suddenly, she developed bradycardia and had a sudden cardiac arrest. An urgent coronary angiogram after resuscitation revealed severe multifocal vasospasm which resolved following high doses of intracoronary vasodilators. Type 1 Kounis syndrome was suspected and she was initiated on intravenous corticosteroids and anti-histamines. Subsequently, she developed cardiogenic shock, and a cardiac magnetic resonance imaging (cMRI) showed diffuse subendocardial late gadolinium enhancement (LGE) suggestive of eosinophilic myocarditis. She was diagnosed with type 1 Kounis syndrome associated with eosinophilic myocarditis. Kounis syndrome should be suspected in patients with refractory vasospastic angina. When indicated, coronary angiography should be performed with administration of intracoronary vasodilators for diagnostic and therapeutic purposes. Although, definite diagnosis of eosinophilic myocarditis requires endomyocardial biopsy, cMRI can be a crucial non-invasive method for establishing the diagnosis.

Successful Treatment of Acute Fulminant Eosinophilic Myocarditis in a Patient with Ulcerative Colitis Using Steroid Therapy and Percutaneous Cardiopulmonary Support

A 47-year-old man with ulcerative colitis was transferred to our hospital due to progressive dyspnea. Electrocardiography on admission showed ST elevation in leads II, III, aVF, and V5-V6. Coronary angiography revealed no remarkable coronary stenosis, and left ventriculography showed a depressed left ventricular ejection fraction (EF) of 23%. Although the patient received percutaneous cardiopulmonary support, his EF progressively decreased (7-15%), and both ventricular tachycardia (VT) and high-degree atrial-ventricular block occurred. An endomyocardial biopsy showed eosinophilic infiltration in the myocardium. Steroid therapy improved the patient's EF. However, his severe inferior wall hypokinesis and non-sustained VT remained after the abovementioned treatment.

Cellular fraction analysis of pericardial effusion helps the diagnosis of eosinophilic myocarditis

Eosinophilic myocarditis is rare in children, and consequently, it is difficult to diagnose eosinophilic myocarditis rapidly. We report the clinical course of acute eosinophilic myocarditis with pericarditis in two adolescent boys and their associated electrocardiograms. The two patients, 13- and 14-year-old boys, developed cardiomegaly and chest pain with vomiting. On examination by two-dimensional echocardiography, thickening of the ventricular septum and a pericardial effusion were detected. The eosinophil count had increased by the pericardial effusion. Acute eosinophilic myocarditis often complicates a moderate to severe pericardial effusion owing to acute pericarditis. A cellular fraction analysis of the pericardial effusion is easy and useful for the diagnosis of eosinophilic myocarditis. Some serial changes in the electrocardiogram occur during each stage of acute eosinophilic myocarditis. They are induced by eosinophilic granules, which are capable of inducing tissue damage and dysfunction, and those changes in the electrocardiogram resemble the changes after an acute myocardial infarction. It is important to know the characteristics of eosinophilic myocarditis in order to prevent lethal complications.

The Clinicopathological Profile of Eosinophilic Myocarditis

Eosinophilic myocarditis (EM) is a rare form of myocarditis. As there is extreme diversity in its manifestations, the true incidence is difficult to assess and no proper epidemiological criteria are present. It generally presents with a wide array of clinical manifestations. Clinical presentation tends to differ in cases and not all the patients show the same signs and symptoms. The etiology of EM often remains obscure but potential causes have been identified which may include hypersensitivity to drugs, exposure to certain viruses and parasites, and hyper-eosinophilic syndromes. Endomyocardial biopsy is considered to be a gold standard for the diagnosis of EM. Echocardiography, cardiac magnetic resonance, and bio markers particularly serum eosinophilic cationic protein concentrations are also known to aid in diagnosis. EM may lead to progressive, irreversible, and fatal myocardial damage if prompt diagnosis is not made and therapy is not initiated. The current treatment regimens include corticosteroids, cytotoxic agents, and immunosuppressive therapy. However, a proper treatment criterion is yet to be established.

Eosinophilia to endomyocardial fibrosis: Documentation of a case

Endomyocardial fibrosis (EMF) is an important cause of restrictive cardiomyopathy in tropical countries. The etiopathogenesis of EMF remains obscure. The role of eosinophilia in the etiopathogenesis of EMF has been debated extensively, but remains unproven. Accordingly, we present a case wherein a patient with documented eosinophilia and heart failure at the age of three-and-a-half years presented with endomyocardial fibrosis at the age of nine years. Such documentation is important to highlight the central role of eosinophils in the pathogenesis of EMF.

Eosinophilic Myocarditis Demonstrated Using Cardiac Magnetic Resonance Imaging in a Patient with Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Disease)

Eosinophilic granulomatosis with polyangiitis (EGPA), historically known as the Churg-Strauss disease, is a small- to medium-sized vessel multi-organ vasculitis with a propensity to involve the heart. EGPA is a rare condition with an estimated annual incidence of one to 4.2 people per million. The cardiac involvement causes significant morbidity and mortality in EGPA patients. Approximately 50% of the deaths in EGPA are related to cardiac disease and occur within the first few months since diagnosis. The current recommendations support evaluation of cardiac involvement by using history, physical exam and multimodality imaging including echocardiogram and cardiac magnetic resonance imaging (CMR). Here, we report a rare case of eosinophilic myocarditis in a 19-year-old patient with EGPA seen on CMR. Pertinent literature is also reviewed. We highlighted the importance of CMR in diagnosing and follow up of EGPA patients.

Eosinophilic Myocarditis With Hypersegmented Granulocytes and Neutrophilia Without Eosinophilia: A Case Mimicking Neutrophilic Myocarditis

We report a case of a 78-year-old woman with neutrophilia without eosinophilia who was pathologically diagnosed with eosinophilic myocarditis by myocardial biopsy. The biopsy specimen showed infiltrating granulocytes with hypersegmentation, mimicking neutrophils; however, they were confirmed to be eosinophils by Giemsa staining.

Eosinophilic Myocarditis: Characteristics, Treatment, and Outcomes

BACKGROUND

Eosinophilic myocarditis (EM) is an acute life-threatening inflammatory disease of the heart. Neither large case series nor clinical trials on this specific myocarditis have been reported.

OBJECTIVES

Based on a systematic revision of all published histologically proven cases, this study aimed to describe the clinical presentation, treatment, and outcome of EM.

METHODS

The study screened 443 manuscripts in MEDLINE and EMBASE on cases of EM published until June 2017. The authors identified 264 patients and included in the main analysis 179 patients admitted to hospital with histologically proven EM.

RESULTS

Median age was 41 years (interquartile range: 27 to 53 years) with similar prevalence in both sexes; pediatric cases (≤16 years of age) accounted for 10.1%. The main symptom at presentation was dyspnea (59.4%), with peripheral eosinophilia observed in 75.9%. Median left ventricular ejection fraction at presentation was 35% (interquartile range: 25% to 50%). The disorders most frequently associated with EM were hypersensitivity and eosinophilic granulomatosis with polyangiitis, which accounted for 34.1% and 12.8% of cases, respectively, whereas idiopathic or undefined forms accounted for 35.7% of cases. Steroids were administered in 77.7% of patients. A temporary mechanical circulatory support (n = 30) was instituted in 16.8% of patients. In-hospital death was 22.3% (n = 40), with the highest occurrence in the hypersensitivity form (36.1%; p = 0.026).

CONCLUSIONS

EM has a poor prognosis during the acute phase, despite a publication bias that could have led to an overestimation of mortality. Associated conditions are identified in approximately 65% of cases. Specific trials and multicenter registries are needed to provide evidence-based treatments to improve in-hospital outcome.

[Eosinophilic Necrotizing Myocarditis Complicated by Myocardial Rupture]

In this female patient eosinophilic myocarditis was complicated by myocardial rupture and hemopericardium with cardiac tamponade. Special features of this case were old age of the patient, fulminant course of the disease, myocardial infarction-like ECG changes, absence of peripheral blood eosinophilia. Presentation is accompanied by discussion of issues of epidemiology, clinical course, diagnostics, and possible causes of eosinophilic myocarditis.

Hypereosinophilic syndrome: endomyocardial biopsy versus echocardiography to diagnose cardiac involvement

OBJECTIVE

To compare echocardiograms and endomyocardial biopsies to diagnose cardiac involvement in hypereosinophilic syndrome.

METHODS

We examined the agreement between echocardiography and endomyocardial biopsies to detect cardiac involvement in hypereosinophilic syndrome by reviewing cases identified as hypereosinophilia or hypereosinophilic syndrome in Mayo Clinic databases from January 1978 through June 2009. Single-organ cases of eosinophilia such as eosinophilic fasciitis and eosinophilic gastroenteritis were excluded. We recorded echocardiogram and endomyocardial biopsy results including biopsy staining for eosinophil granule major basic protein (if performed). Clinical and laboratory features documented included presenting symptom(s), maximum total eosinophil count, dose of prednisone (if any) and eosinophil count at the time of endomyocardial biopsy, cardiac enzymes, serum tryptase level, electrocardiogram result, the result of testing for the FIP1L1-PDGFRA fusion gene, complications associated with the biopsy procedures and available follow-up information.

RESULTS

From a total of 387 patients' records screened 288 met the criteria for hypereosinophilic syndrome and of these 240 had echocardiograms. Among these patients there were 138 normal echocardiograms, 67 had echocardiograms without findings of hypereosinophilic syndrome but with one or more other abnormalities, and 35 had echocardiograms with findings consistent with hypereosinophilic syndrome. Twenty-five patients from this group of 35 patients had both echocardiogram and endomyocardial biopsy. In 15 patients there was agreement between both endomyocardial biopsy and echocardiography as to the presence (n = seven) or absence (n = eight) for findings of cardiac involvement. In 10 of 25 patients test results diverged: 3 patients with positive echocardiographic changes did not have confirmatory findings by endomyocardial biopsy and seven patients with positive biopsy findings had echocardiograms without findings of hypereosinophilic syndrome.

CONCLUSIONS

Echocardiograms and endomyocardial biopsies agree for presence or absence of cardiac involvement 60% of the time. Endomyocardial biopsy detected cardiac involvement in 7 patients in whom the echocardiogram was negative for findings of hypereosinophilic syndrome.

A Pitfall in the Diagnosis of Eosinophilic Myocarditis in a Patient who Received Steroid Therapy

Eosinophilic myocarditis is a rare form of myocardial inflammation that is characterized by the infiltration of eosinophilic cells into the myocardium. The clinical symptoms of eosinophilic myocarditis are similar to those of acute coronary syndrome, and eosinophilic myocarditis sometimes occurs in combination with bronchial asthma. We herein present a case of eosinophilic myocarditis in which additional time was required to make a definitive diagnosis because the patient received steroid therapy. The diagnosis of eosinophilic myocarditis is challenging, especially when a patient has other inflammatory diseases, such as bronchial asthma. We should pay attention to the possibility that steroid therapy may mask the presentation of eosinophilic myocarditis.

Clozapine-associated cardiac dysfunction during a gastroenteritis outbreak

We report that two young adult patients who were initiated with clozapine for severe psychosis during a hospital-wide gastroenteritis outbreak went into severe shock. Neither patient had troponin elevation. Each required left ventricular assist device support for myocarditis. Endomyocardial biopsy revealed lymphocytic myocarditis in one patient and eosinophilic myocarditis in the other. The former patient expired. Polymerase chain reaction testing was negative for Coxsackie virus. These two patients illustrate that myocarditis can occur at usual incipient doses and that there may be an epidemiologic risk associated with gastroenteritis. Although the white blood cell (WBC) count is expected to decrease with clozapine, these patients had persistently elevated WBC counts. In conclusion, physicians should exercise caution when prescribing clozapine, especially for those with diarrhea.

Echocardiographic Changes in Eosinophilic Endocarditis Induced by Churg-Strauss Syndrome

Eosinophilic myocarditis may be accompanied by Churg-Strauss syndrome (CSS). We report a case of CSS that was accompanied by myocardial changes in the early stage. A 71-year-old woman complained of mild chest pain at rest, but routine echocardiography did not reveal any endocardial abnormalities. Four months later, the patient was hospitalized due to congestive heart failure with neuropathy of both upper extremities. A diagnosis of eosinophilic myocarditis was made based on the patient's laboratory results and the presence of mural thrombus. This case illustrates that, although early eosinophilic myocarditis is an important differential diagnosis in patients with chest pain, it may be difficult to identify in without an apparent mural thrombus.

Myocarditis in drug rash with eosinophilia and systemic symptoms

Drug rash with eosinophilia and systemic symptoms is a drug hypersensitivity reaction. Hepatitis and nephritis are the most common visceral manifestations. Myocarditis is important to recognise, given the high mortality rate. We describe a child with drug rash with eosinophilia and systemic symptoms and discuss the role of N-terminal pro-hormone of basic natriuretic peptide in early recognition of associated myocarditis.

Fatal sulfasalazine-induced eosinophilic myocarditis in a patient with periodic fever syndrome

OBJECTIVE

The aim of this paper is to report the first case of drug-induced eosinophilic myocarditis (EM) in a patient with hereditary periodic fever syndrome (PFS).

CASE

A 28-year-old man with hyper-IgD syndrome, one of the PFS, developed a sulfasalazine-induced systemic hypersensitivity reaction complicated by EM. Thirteen days after sulfasalazine introduction, which had been given for arthritis, the patient developed fever, facial/neck edema, rash and cardiogenic shock, and died within 8 h. The autopsy revealed hemophagocytosis, while acute heart failure caused by necrotizing EM was established as the cause of death.

CONCLUSION

This was a case of drug-induced EM in a patient with PFS that had an atypical presentation, rapid evolution and poor outcome.

Effects of monoclonal antibodies to adhesion molecules on eosinophilic myocarditis in Toxocara canis-infected CBA/J mice

Eosinophilic myocarditis followed by fibrosis of the cardiac muscle was observed in addition to peripheral blood eosinophilia in CBA/J mice infected with Toxocara canis. The infected mice were used as an experimental model of eosinophilic endomyocarditis associated with hypereosinophilic syndrome. Effects of in vivo treatment with MoAbs to adhesion molecules on eosinophilic myocarditis were examined using this experimental model. Expressions of intercellular adhesion molecule-1 (ICAM-1) and vascular cell adhesion molecule-1 (VCAM-1) on endothelial cells of capillaries in myocardium were increased 1 and 2 weeks after infection. Infiltration of very late antigen (VLA)-4+ and/or CD11a+ cells into the cardiac muscles was also observed 1 and 2 weeks after infection. Infiltration of eosinophils into the heart was significantly suppressed by anti-CD18 MoAb and anti-VLA-4 MoAb, and focal fibrosis of the cardiac muscle was also significantly suppressed by combined administration of anti-CD18 and anti-ICAM-1 MoAbs. These results indicate that adhesion molecules may play important roles in eosinophilic myocarditis, and that blockade of interaction between adhesion molecules and their ligands may help to control it.