SPC365

A case of Löeffler's endocarditis caught just on time

Session: Prémio Melhor Caso Clínico
Speaker: Joana Silva Ferreira

Congress: CPC 2023
Topic: P. Other
Theme: 37. Miscellanea
Subtheme: ---
Session Type: Sessão de Prémios
FP Number: ---
Authors: Joana Silva Ferreira; Jéni Quintal; Rui Coelho; Ana Fátima Esteves; Sara Gonçalves; Tatiana Duarte; João Abecasis; Rui Caria
<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><span style="color:black">A 46-year-old female with a history of vitiligo and immune&nbsp;thrombocytopenic purpura&nbsp;presented to the Emergency Department (ED) with a 4-week history of fatigue and orthopnea. She had previously been to the ED nearly 2 months before with high fever and fatigue and was diagnosed with a viral infection and discharged on antipyretics.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><span style="color:black">On physical examination she now presented signs of pulmonary congestion including bilateral pleural effusion as well as mild peripheral edema.&nbsp;Her bloodwork revealed an NT-proBNP of 16.600 pg/mL, a mildly elevated troponin (41 pg/mL), peripheral eosinophilia (1400/</span><span style="color:black">&mu;</span><span style="color:black">L, &nbsp;increasing up to 5000/</span><span style="color:black">&mu;</span><span style="color:black">L) and a mildly elevated CRP (5 mg/dL).</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><span style="color:black">A transthoracic echo (TTE) showed a non-dilated left ventricle (LV) with endocardial hyperechogenic thickening which obliterated the apex. LV filling showed a restrictive pattern, and the ejection fraction was mildly reduced (49%). The right ventricle was dilated with a compromised systolic function and SPAP was estimated at 55mmHg.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><span style="color:black">Over the following 24 hours, she went into cardiogenic shock and was started on noradrenaline and dobutamine.&nbsp;High-dose corticosteroids followed by hydroxyurea were also&nbsp;started but were ineffective. Despite the still uncontrolled eosinophil count, her hemodynamic and clinical condition began to improve on the 5<sup>th</sup> day of hospitalization.</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><span style="color:black">Cardiac magnetic resonance (CMR) revealed subendocardial late gadolinium enhancement (LGE) with overlapping thrombotic material with an apical double-V aspect, associated with signs of myocardial inflammation (increased T1 and T2 values). Overall, the findings on multimodality imaging associated with the hypereosinophilia were highly suggestive of L&ouml;effler&rsquo;s endocarditis. </span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><span style="color:black">From the additional etiologic studies, we highlight a myelogram with a hypercellular myeloid series with 18% eosinophil and normal bone biopsy. Extensive hematologic studies (including T lymphocyte phenotyping and genetic testing) were normal. Autoimmune disease, parasite infection and malignancy were also excluded. </span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><span style="color:black">After the failure of corticosteroids and hydroxyurea, she was started on imatinib, which finally led to a full control of the eosinophil count. The patient was discharged to the heart failure clinic on neurohormonal medication, warfarin and imatinib. </span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><span style="color:black">During follow-up, her clinical condition continued to improve (currently in NYHA class I-II).&nbsp;At 5&nbsp;months post-discharge, CMR no longer showed any thrombotic material and revealed an improvement in&nbsp;biventricular systolic function (LV ejection fraction 56% and RV ejection fraction of 49%).&nbsp;</span></span></span></span></p>

<p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Calibri,sans-serif"><span style="color:#000000"><span style="color:black">This is a rare case of L&ouml;effler&#39;s endocarditis (secondary to idiopathic eosinophilia) with a very severe presentation but surprisingly good outcome.</span></span></span></span></p>