Time course of eosinophilic myocarditis visualized by CMR

Abstract

We report the diagnostic potential of cardiovascular magnetic resonance (CMR) to visualize the time course of eosinophilic myocarditis upon successful treatment. A 50-year-old man was admitted with a progressive heart failure. Endomyocardial biopsies were taken from the left ventricle because of a white blood cell count of 17000/mm 3 with 41% eosinophils. Histological evaluation revealed endomyocardial eosinophilic infiltration and areas of myocyte necrosis. The patient was diagnosed with hypereosinophilic myocarditis due to idiopathic hypereosinophilic syndrome. CMR-studies at presentation and a follow-up study 3 weeks later showed diffuse subendocardial LGE in the whole left ventricle. Upon treatment with steroids, CMR-studies revealed marked reduction of subendocardial LGE after 3 months in parallel with further clinical improvement. This case therefore highlights the clinical importance of CMR to visualize the extent of endomyocardial involvement in the diagnosis and treatment of eosinophilic myocarditis. Case reportA 50-year-old man was admitted with a suspicion of an acute coronary syndrome because of progressive dyspnea and positive Troponin I (9.5 ng/ml). A two-dimensional echocardiogram revealed severe left ventricular hypokinesis with an ejection fraction of 27%. Upon coronary angiography, coronary artery disease was excluded. Because of a white blood cell count of 17000/mm 3 with 41% eosinophils, endomyocardial biopsies were taken from the left ventricle. Histological evaluation showed marked endomyocardial eosinophilic infiltration and areas of myocyte necrosis ( Figure 1A). Further evaluation revealed no evidence of secondary hypereosinophilia (malignant diseases, allergy, vasculitis, parasitic infection). The patient was diagnosed with hypereosinophilic myocarditis due to idiopathic hypereosinophilic syndrome. Medication with steroids and heart failure was initiated promptly and the patient improved rapidly.CMR-studies at presentation and a follow-up study 3 weeks later showed diffuse subendocardial LGE in the whole left ventricle with involvement of the papillary muscles. Upon 3 months follow up, however, subendocardial LGE has markedly decreased in parallel with further clinical improvement ( Figures 1B,C,D). Ejection fraction has improved from 27% at baseline to 35% after

The Use of Contrast-Enhancement Cardiovascular Magnetic Resonance Imaging in Cardiomyopathies

“…The subendocardium is generally not involved, with the exception of eosinophilic myocarditis, which frequently involves the endomyocardium (Figure 7a). (Bohl et al, 2008;Deb et al, 2008). In chronic myocarditis, besides an increased edema on T2-weighted imaging, an increased global relative enhancement is a common finding as confirmed in immunohistological analyses.…”

MRI-based Evidence for Myocardial Involvement in Women with Hypereosinophilic Syndrome

“…In fact, different scenarios have been reported in the course of active myocarditis in HES including the complete resolution of myocarditis and persistence of LGE lesions in the myocardium. 10,28,36 In addition, both scenarios were also observed in other types of myocardial inflammation, including vasculitis and viral etiology, and were linked to prognosis. 31,32 Prior case reports documented the ability of CMR to depict eosinophilic myocarditis in HES confirmed by endomyocardial biopsy.…”

“…31,32 Prior case reports documented the ability of CMR to depict eosinophilic myocarditis in HES confirmed by endomyocardial biopsy. 9,25,28 In the current study, despite the apparent clinical and laboratory control of disease, 3 women demonstrated CMR evidence of myocarditis. Of note, CMR abnormalities were associated with higher levels of blood eosinophil count, that reflects the role of eosinophils in myocardial inflammation.…”

Treatment‐refractory idiopathic hypereosinophilic syndrome: Pitfalls and progress with use of novel drugs

“…Echocardiography is often unremarkable in the acute phase of eosinophilic myocarditis [8], and CMRI can be useful in detecting the disease at an early stage [9]. Endomyocardial biopsy is often useful in confirming a diagnosis of CM and was considered in this case, but was deferred given the high associated risk in the setting of recent cardioembolic strokes and the consequent ongoing need for anticoagulation.…”