A case report of myocardial infarction with non-obstructive coronary arteries as the initial presentation of eosinophilic granulomatosis with polyangiitis

Abstract

Background Eosinophilic granulomatosis with polyangiitis (EGPA) is a multisystem disorder commonly affecting the lung and skin, with cardiovascular involvement found in up to 60% of patients. We present a case of myocardial infarction with nonobstructive coronary arteries (MINOCA) as the initial presentation of EGPA. Case Summary A 52-year-old female with past medical history of asthma, recurrent sinusitis and peripheral neuropathy presented to our hospital with chest pain, rash, acute vision loss, elevated troponin and peripheral eosinophilia. Electrocardiogram showed no ischaemic changes and coronary angiography displayed normal coronary anatomy. On a subsequent visit, cardiac magnetic resonance (CMR) showed predominant focal anteroseptal and inferoseptal akinesis with focal sub-endocardial delayed enhancement, indicative of a myocardial infarction involving the septal branches of the left anterior descending artery. Due to the focal findings on CMR, peripheral eosinophilia, and rash, the patient was evaluated for EGPA. Rheumatologic workup and skin biopsy were suggestive of small vessel vasculitis. The patient was diagnosed with multi-organ EGPA, involving the coronaries, which was ultimately thought to be the etiology of her MINOCA. Following steroid and monoclonal antibody therapy, the patient experienced notable improvement in her cardiac function at Follow-up appointments. Discussion This is a unique case MINOCA as the initial presentation of EGPA. Considering the heterogenous disease presentation of those diagnosed with MINOCA, utilization of CMR is essential to guide diagnosis and management of such patients.

Myocardial Infarction With Non-obstructive Coronary Arteries: An Updated Overview of Pathophysiology, Diagnosis, and Management

“…On the electrocardiogram (ECG), they usually have non-ST segment elevation myocardial infarction (NSTEMI). It is important to note that the clinical presentation of MINOCA patients varies due to the many causes of the illness [ 27 - 28 ].…”

Cardiovascular pathology in vasculitis

“…Most reported cases occur in children with KD, and its final diagnosis requires a strict clinicopathological correlation with the extracardiac manifestations of the disease 9 . However, and usually at older ages, coronary vasculitis could represent also as an underdiagnosed condition in the clinical setting of myocardial infarction without occlusive coronary artery disease, occurring in patients with an autoimmune systemic disease or with an isolated inflammatory coronary disorder 10-13 .…”