Eosinophilic myocarditis: a diagnostic challenge and treatment dilemma-a case report

Abstract

Background: Eosinophilic myocarditis, a rare and potentially life-threatening condition, can resemble acute coronary syndrome (ACS) and presents diagnostic difficulties.

Case report: We describe the case of a 32-year-old man initially admitted with ACS-like symptoms, but ultimately diagnosed with eosinophilic myocarditis. The patient presented with intense retrosternal chest pain, significant eosinophilia, and elevated cardiac enzymes. Despite clinical indications suggesting myocardial involvement, an endomyocardial biopsy was not performed due to the patient's reluctance. Non-invasive imaging and clinical findings led to the presumptive diagnosis of eosinophilic myocarditis. The patient was treated with high-dose corticosteroids and immunosuppressive therapy, resulting in clinical improvement.

Discussion: Our report highlights the importance of considering eosinophilic myocarditis and hypereosinophilic syndrome when evaluating patients with chest pain and hypereosinophilia. It emphasizes the subtleties of diagnosis and the critical need for early identification and appropriate treatment to improve prognosis in cases of eosinophilic myocarditis. This case underscores the diverse clinical manifestations of myocarditis and the essential need for a comprehensive diagnostic approach in the presence of chest pain and hypereosinophilia.

Keywords: Acute coronary syndrome; Case report; Hypereosinophilic syndrome; Minoca; Myocarditis.

Figure 1

Parasternal long-axis echocardiographic section showing a dilated left ventricle with a telediastolic diameter of 77 mm.

Figure 2

Echocardiographic sections showing thrombi. (A and B) Short-axis parasternal section passing through the root of the great vessels. (C) Apical four cavities centred on the RV. (D) Modified short-axis parasternal section centred on the trunk of the pulmonary artery. Red stars, thrombi; RA, right atrium; LA, left atrium; RV, right ventricle; LV, left ventricle; Ao, aorta.

Figure 3

(A) Axial thoracic scan showing the same thrombi seen on transthoracic echocardiography (red stars) as well as cardiomegaly and dilatation of the left ventricle. (B) Axial thoracic scan showing ground glass (red arrow) opacities and pleural effusion (blue arrow). RA, right atrium; RV, right ventricle; LV, left ventricle.

Figure 4

T2 mapping sequences: black and white and colour images (basal, mid, and apical sections) revealed elevated zones of T2 mapping particularly in septal wall indicative of diffuse myocardial oedema.

Figure 5

Late gadolinium enhancement cardiac magnetic resonance two-chamber and four-chamber sequences showing non-segmented subepicardial patchy enhancement patterns in favour of myocarditis. The late gadolinium enhancement is more marked in the anterior, anteroseptal, and inferior walls. Red arrows: late gadolinium enhancement.