Loeffler endocarditis with intracardiac thrombus: case report and literature review

Abstract

Background Loeffler endocarditis is a relatively rare and potentially life-threatening heart disease. This study aimed to identify the characteristic features of Loeffler endocarditis with intracardiac thrombus on a background of hypereosinophilic syndrome (HES). Case presentation We described a 57-year-old woman with Loeffler endocarditis and intracardiac thrombus initially presenting with neurological symptoms, who had an embolic stroke in the setting of HES. After cardiac magnetic resonance (CMR), corticosteroids and warfarin were administered to control eosinophilia and thrombi, respectively. During a 10-month follow-up, the patient performed relatively well, with no adverse events. We also systematically searched PubMed and Embase for cases of Loeffler endocarditis with intracardiac thrombus published until July 2021. A total of 32 studies were eligible and included in our analysis. Further, 36.4% of recruited patients developed thromboembolic complications, and the mortality rate was relatively high (27.3%). CMR was a powerful noninvasive modality in providing diagnostic and follow-up information in these patients. Steroids were administered in 81.8% of patients, achieving a rapid decrease in the eosinophil count. Also, 69.7% of patients were treated with anticoagulant therapy, and the thrombus was completely resolved in 42.4% of patients. Heart failure and patients not treated with anticoagulation were associated with poor outcomes. Conclusions Cardiac involvement in HES, especially Loeffler endocarditis with intracardiac thrombus, carries a pessimistic prognosis and significant mortality. Early steroids and anticoagulation therapy may be beneficial once a working diagnosis is established. Further studies are needed to provide evidence-based evidence for managing this uncommon manifestation of HES.

Eosinophilic Myocarditis presenting with progressive Cardiac Cachexia

“…Eosinophilic myocarditis is associated with high morbidity and mortality rates. Particularly presence of intracardiac thrombi and signs of heart failure is associated with significantly poor prognosis, reaching nearly 30% mortality (6). As demonstrated also in our case, advanced stage of eosinophilic myocarditis led to progressive cardiac cachexia resulting in patient's death, despite initiated intensive treatment.…”

“…It is caused by eosinophil infiltration of the endomyocardium with subsequent tissue damage and endomyocardial fibrosis (5). Clinical manifestations include signs of heart failure, arrhythmias, or embolic events caused by intracardiac thrombi (4,6). We present a case of a patient with eosinophilic myocarditis clinically manifesting with progressive cardiac cachexia.…”

Systemic thrombo-embolic events in a middle-aged male with Loeffler endocarditis without peripheral eosinophilia—a case report

“…Impaired tissue and organ function cause high morbidity and mortality [ 3 ]. Prognosis in LE therefore is poor due to high mortality from heart failure, sudden cardiac death or thrombo-embolism due to LV thrombus formation [ 12 , 19 , 20 ]. In a prospective study of 25 patients by Parrillo JE et al [ 21 ], dyspnea was the most common symptom (42%), followed by chest pain (27%), heart failure (38%), cough (12%), palpitations (8%) and thrombo-embolic events (4%).…”

“…It is also believed that eosinophils may contribute to thrombus formation by binding to thrombomodulin and impairing the inherent anticoagulant properties of the endothelial membrane [ 24 ]. CMR imaging is a powerful noninvasive modality in providing diagnostic and follow-up information in these patients, in particular if suspicious for the diagnosis of LE with thrombus formation, however, not possible in our case [ 12 , 18 ]. EMB remains the gold standard, confirming the diagnosis also in our case, although containing risks, such as sampling errors or iatrogenic embolism [ 18 , 25 ].…”

“…Aiming the optimal therapeutic strategy for our patient, immunosuppressive therapy was started after confirming the diagnosis by EMB. Considering LE patients with an intracardiac thrombus formation in a review including 32 studies, steroids were administered in 81.8% of patients, achieving a rapid decrease in the eosinophil count [ 12 ]. As no peripheral eosinophilia was present in our case, this therapeutic effect was not measurable.…”