Pulmonary Adenocarcinoma Presenting as Acute Heart Failure and Hypereosinophilia

Abstract

Hypereosinophilia is a serum eosinophil count of over 1,500 eosinophils/µL. It is an uncommon laboratory finding, and it can be asymptomatic or associated with organ damage, in which case it is referred to as hypereosinophilic syndrome. It can be primary, when the expansion of eosinophils occurs in the setting of a hematological neoplasm, or secondary, when it is caused by an external stimulus, such as a parasitic infection or a solid neoplasm. We present a case of hypereosinophilia diagnosed in a patient presenting with acute heart failure initially attributed to coronary disease and alcohol consumption. Due to persisting eosinophilia with no apparent cause, eventually reaching more than 41,000 eosinophils/µL, a full-body scan was performed, showing the presence of a peri-hilar mass partially obstructing the left main bronchus and multiple lesions in the liver and thoracic vertebrae. The liver biopsy revealed metastatic non-small cell lung carcinoma. Around the time the biopsy was performed, the patient began complaining of new-onset chest paint, and the diagnoses of pulmonary embolism and later lung abscess were made, the reasons why he had no conditions to begin chemotherapy. The medical condition of the patient deteriorated in the next few days, and the patient died six months after the initial diagnosis of hypereosinophilia.

Keywords: acute heart failure; acute myocardial infarction; hypereosinophilia; lung abscess; lung cancer.

Figure 1. Eosinophil count since the first hospital admission

The eosinophil count started normal and progressively increased since the first hospital admission for acute heart failure, reaching the impressive value of 40,000 eosinophils/uL; this high count is what motivated the search for an underlying diagnosis, despite the patient being totally asymptomatic.

Figure 2. Lung peri-hilar mass obliterating the left main bronchus

A large lung mass located in the left peri-hilar and peri-cardiac regions is apparent; it is spiculated and poorly defined, which, in association with the impressive hypereosinophilia that the patient presented with, made the diagnosis of lung malignancy likely.

Figure 3. Lung peri-hilar mass hiding behind the cardiac shadow

In the coronal view, we can see that the lung mass, albeit its important size, is largely hidden behind the cardiac silhouette, which justified why it was not apparent in the posteroanterior view of the X-ray.

Figure 4. Liver metastasis

During the staging of the carcinoma, multiple liver metastases were apparent in the abdominal CT scan; two of the largest ones are marked with gray arrows.

Figure 5. Vertebrae metastasis

The staging also intended to search for eventual bone involvement and found a metastasis in the fifth thoracic vertebra, which was marked with a gray arrow.

Figure 6. Lung abscess

The patient was readmitted to the hospital with high fever and dyspnea caused by superinfection of the neoplasm region, with the formation of the lung abscess shown in the figure, with an evident gas-fluid level.