Acute Necrotizing Eosinophilic Myocarditis with Giant Cell Infiltration after Remission of Idiopathic Thrombocytopenic Purpura.

Abstract

Acute necrotizing eosinophilic myocarditis is characterized by acute onset, fulminant congestive heart failure, and extensive necrosis of myocytes with striking eosinophilic infiltration. However, multinucleated giant cells sometimes appear in the fulminant phase of severe myocarditis. This is the first case of a patient with a 1 year previous history of idiopathic thrombocytopenic purpura, whopresented with acute necrotizing eosinophilic myocarditis with giant cell infiltration. (Internal Medicine 36: 894-897, 1997) Key words: eosinophils, hypereosinophilic syndrome, giant cell myocarditis Case ReportA 41-year-old manwas referred to our hospital for evaluation of cardiac failure on May 31, 1995. He had a past history of idiopathic thrombocytopenic purpura (ITP) in April 1994 when he complained of purpura at his extremities and bleeding in his oral cavity. At that time, his platelet count was markedly reduced to 2.0xl09//. The white blood cell (WBC)count was 6.2x109//with 5% eosinophils. He was diagnosed as having ITP at another hospital on the basis of an elevated level of platelet- (25 g/day for 5 days) effectively and rapidly improved his platelet count to 308x109// nine days later. Then, the dosage of prednisolone was reduced by 5 mg per week and discontinued 1 month later. In September 1994, his platelet count was 359xl09//andWBC countwas 9.0xl09//with 16% eosinophils. Thereafter, he did not consult a doctor because he recovered from ITP without recurrence. On May 26, 1995, he began to complain of dyspnea and general fatigue without any preceding clinical symptomsof infection. He consulted a doctor again and was noted to have an electrocardiogram (ECG) abnormality, elevated levels of myocardial enzymes, and pericardial effusion. Because of sustained hypotension in spite of treatment with catecholamines, he was transferred to our hospital for further evaluation. On admission, he had a body temperature of 37.5 degrees centigrade, blood pressure of 94/70 mmHg, heart rate of 1 10 beats/min, and a respiratory rate of 24/min. His jugular veins were markedly dilated. Heart auscultation revealed the presence of a gallop rhythm, but no crackles were audible. There was no peripheral edema. Neither Osier' s painful spot nor splinter hemorrhagewas noted. The ECGshowed sinus tachycardia, complete right bundle branch block, left posterior hemiblock, and a low voltage in peripheral leads (Fig. 1). The chest radiograph showed cardiomegaly and moderate pulmonary congestion (Fig. 2). The 2-dimensional echocardiography showed diffuse hypokinesis of the left ventricle (LV) and an apparent pericardial effusion. LV wall thickness was increased to 20 mmat the interventricular septum and to 14 mmat the posterior wall. The LVejection fraction was 28%. Laboratory data on admission were as follows: WBCcount of 8.3xl09// with an increased eosinophils (21%). Red blood cell (RBC) count of 4,700x109//, hemoglobin of 150 g/Z, and a platelet count of 209x109//. The erythrocyte sedimentation rate was 26 mm/h. The lactate dehydrogenase (L...

Natural Killer Cells Limit Cardiac Inflammation and Fibrosis by Halting Eosinophil Infiltration

“…56,57 Clinically, infiltrating eosinophils are found in severe giant cell myocarditis and these patients, along with necrotizing eosinophilic myocarditis, have poor clinical prognosis. 58,59 Other clinical entities in which moderate levels of eosinophils are found infiltrating the myocardium include hypersensitivity and drug reactions, parasitic infections, vasculitis and granulomatous diseases, and idiopathic hypereosinophilic syndrome. 60 Little is known about the cardiac eosinophil profile; however, in all cases, cardiac necrosis, thrombosis, and fibrosis are found.…”

Eosinophilic myocarditis without hypereosinophilia accompanied by giant cell infiltration

“…Accordingly, giant cells can appear in eosinophilic myocarditis if the inflammation is severe. Hyogo et al, for example, reported a case of acute necrotizing eosinophilic myocarditis with giant cell infiltration [7]. We diagnosed this case as eosinophilic myocarditis, in spite of the presence of giant cells, for several reasons including the infiltration of the myocardium with numerous eosinophils, the patient's history of allergic disease, and the condition of the patient, which was not as critical as that associated with giant cell myocarditis.…”

Loffler's Endocarditis Presenting in 2 Children as Fever With Eosinophilia

“…13 The mechanism of damage to the endocardium and later to the myocardium is mediated by the eosinophils' specific granule proteins, such as cationic major basic protein and peroxidase, which accumulate on the endocardial surface. 4 Electrocardiographic abnormalities comprise intraventricular conduction disturbances 15 and ST-T changes 12 with evidence of right or left ventricular hypertrophy. 3,8 Cellular damage to the myocyte is mediated by reactive oxygen species such as hydrogen peroxide released by peroxidase.…”