Cardiac MRI findings of endomyocardial fibrosis (Loeffler's endocarditis) in a patient with rheumatoid arthritis

Abstract

Loeffler's endocarditis and cardiac manifestations of the hypereosinophilic syndrome (HES) are rare and difficult to diagnose. We report a case of in a 36 year-old female with a history of rheumatoid arthritis with disabling dyspnea. The transthoracic echocardiogram demonstrated normal systolic cardiac functions and a left ventricular apical thrombus. However, using cardiovascular magnetic resonance (CMR) with inversion-recovery (IR) delayed enhancement, and cine steady-state free precession (SSFP) sequences, we were able to clearly demonstrate endocardial fibrosis, tissue inflammation, apical ventricular hypertrophy, and LV thrombus that correlate with clinical findings. We believe cardiac MRI is more useful than transthoracic echocardiography in the diagnosis and management of HES and ultimately it obviated the need for biopsy to confirm the diagnosis.

Keywords: CMR; Hypereosinophilic syndrome; Loeffler’s endocarditis.

Figure 1

Inversion recovery images 10 min after contrast injection showing left ventricular apical thrombus (red circles) and sub-endocardial enhancement (blue arrows).

Figure 2

SSFP axial view showing apical bi-ventricular hypertrophy with obliteration of the RV apex.

Figure 3

SSFP two-chamber view showing dark jet artifact during left ventricle systole across the mitral valve into the left atrium denoting mitral valve insufficiency.

Figure 4

SSFP two-chamber view showing pericardial effusion.