reference limit, 125 pg/ml) and eosinophilia reached 64.5%. Cardiac MRI (considered an excellent tool to diagnose heart involvement in EGPA) 2 revealed lesions corresponding with endomyocardial inflammatory infiltration and thrombosis in both ventricles ( Figure 1AB). Perinuclear antineutrophil cytoplasmic antibody (pANCA) titer was positive (1:80). Based on the clinical picture and test results, we suspected EGPA. The patient was treated with methylprednisolone (3 intravenous pulses of 0.5 g followed by 32 mg/d orally) and with subcutaneous enoxaparin followed by warfarin. His general status improved within a few days, and pANCA titer decreased to 1:10 after 3 months. Methylprednisolone was tapered to a maintenance dose of 4 mg/d. Echocardiography was performed regularly during follow-up to monitor regression of cardiac lesions. Follow-up cardiac MRI was repeated at 3 months and revealed complete resolution of infiltrative and thrombotic lesions ( Figure 1CD). Currently, the patient is in an excellent general condition and is awaiting a kidney transplant.Patients with ESRD caused by small vessel vasculitis are carefully monitored because life-threatening nonrenal flares (including cardiac manifestations) are common (especially in granulomatosis with polyangiitis).3,4 However, in our patient, the early (prodromal) symptoms of the disease during a predialysis period were overlooked (probably because another cause of ESRD was established, and no other ACR criteria were fulfilled at the onset of the disease). The patient presented with a fulminant, life-threatening flare while already on hemodialysis.Eosinophilic granulomatosis with polyangiitis (EGPA, formerly known as Churg-Strauss syndrome) is a rare autoimmune vasculitis with an incidence of less than 3 cases per million. Heart involvement is observed in 27% to 47% of the patients and remains the main predictor of poor long-term prognosis and premature mortality, although it is not included in the diagnostic criteria of EGPA developed by the American College of Rheumatology (ACR). 1We present the results of cardiac magnetic resonance imaging (MRI) in a patient on chronic hemodialysis (end-stage renal disease [ESRD] secondary to reflux nephropathy followed by nephrectomy) who developed progressive heart failure due to EGPA.A 34-year old man was referred to a renal clinic with advanced chronic kidney disease (estimated glomerular filtration rate, 26 ml/min/1.73 m 2 ). He was diagnosed with vesicoureteral reflux soon after birth. Because of complications, he underwent right-side nephrectomy in early childhood and received conservative treatment for the next 3 years until ESRD developed. Owing to nonspecific symptoms from the upper respiratory tract and occasional eosinophilia (7%-24%), he was consulted by a pulmonologist and diagnosed with asthma. He received fluticasone/salmeterol and levocetirizine. At the age of 37, soon after hemodialysis was started, he was admitted to the Department of Nephrology with fever and acute dyspnea. Echocardiography revealed large ...

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