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Diastolic heart failure - As bad as it gets, before it gets better
1Institute of Cardiovascular Diseases Prof. C.C. Iliescu, cardiology - Bucharest - Romania
2Medlife - Brasov - Romania
Introduction: We report the case of a 43-year-old patient, known with professional exposure to dust, ex- smoker, who complains of fatigue, exertional dyspnea, night sweats and weight-loss for several months. The physical examination revealed axillary adenopathy and hepatosplenomegaly. His laboratory tests showed hypereosinophilia, trombocytopenia, polyglobulia and raised BNP levels. He was first evaluated by the haematologist and the suspicion of a myeloproliferative disease was raised.
Problem, patient management: His transthoracic echocardiogram revealed a cardiac mass attached to the apical and anterior wall of the left ventricle with a maximum thickness of 19 mm, a restrictive diastolic filling pattern, reduced myocardial velocities – all in favour of intrinsic cardiomyopathy. For a better evaluation, cardiac MRI was performed which showed a biventricular involvement (masses attached to the apical free wall of both ventricles- Image A, subendocardial late gadolinium enhancement of both ventricles), being highly suggestive of hypereosinophilic myocarditis. Different hematological tests in search for a possible etiology were performed (bone marrow biopsy and JAK2, BCR-ABL, PDGFR, c-MPL, CALR mutations), with negative results. A parasitologic panel obtained a positive Toxocara canis IgG result. The diagnosis of chronic eosinophilic leukemia was established by the haematologist. His treatment included corticotherapy, hydroxyurea, oral anticoagulation, betablocker and diuretics, which was well tolerated.
Questions, problems, possible differential diagnosis: The mechanism for hypereosinophilia in this case was uncertain at the beginning, with multiple possible causes : myeloproliferative syndrome/neoplastic disease (because of multiple organ involvement, laboratory tests), parasitic disease, allergic disease (previous professional exposure to dust). Also, it was decided to use a vitamin K antagonist, due to the uncertain benefits of novel anticoagulants in this setting.
Conclusions: Loeffler endocarditis is a condition resulting from various eosinophilic diseases, including parasitosis, drug hypersensitivity, systemic vasculitis or idiopathic hypereosinophilic syndromes. „True" hypereosinophilic syndrome is considered rare. Sometimes, it proves to be challenging to ascertain the etiology, as it was in this case and it is also of great importance for establishing the prognosis.
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