Case Review Session 4: Non-ischemic Cardiomyopathies
4 - Clinical Course and CMR-Characteristics of Fulminant Eosinophillic Myocarditis – Case Report
Friday, February 14, 2020
1:45 PM – 1:55 PM
Location: Salon J1
Description of Clinical Presentation: A sixty-eight-year-old female patient presented with acute chest pain, dysarthria and attention deficit. A cranial CT scan showed no signs of stroke or intracranial haemorrhage. After a working diagnosis of non-ST-elevation troponin positive acute coronary syndrome has been made, only minimal luminal irregularities could be demonstrated on coronary angiography. Otherwise inconspicuous blood count showed marked eosinophilia. Following CMR raised suspicion for eosinophilic myocarditis. This was subsequently confirmed by myocardial biopsy and anti-inflammatory medication with prednisolone and methotrexate was initiated. As the neurologic symptomatology was deemed as a result of thromboembolism, oral anticoagulation with apixaban was started.
Diagnostic Techniques and Their Most Important Findings: On admission as well as at 2 and 20 weeks follow-up a CMR study was performed on a 1.5 Tesla (MAGNETOM Aera, Siemens Medical Imaging, Erlangen, Germany) scanner. The imaging protocol included multi-planar localizers, cine acquisitions, T1-, T2-mapping and rest perfusion scan. Approximately 15 minutes after injection of contrast agent (0.15 mmol/kg IV gadoterate meglumine (Dotarem®, Guerbet, USA), late gadolinium enhancement (LGE) data were acquired. Initial CMR scan showed slightly reduced left ventricular ejection fraction, which improved on follow-up (45%, 51% and 52% at presentation, 2 and 20 weeks respectively). Perfusion scan demonstrated circumferential subendocardial perfusion deficit, which was not present on follow-up. This corresponded with circumferential subendocardial late gadolinium enhancement, which was still present at 2 weeks but barely visible at 20 weeks follow-up. The course myocardial T1 values (1348ms, 1081ms and 1061ms at presentation, 2 and 20 weeks respectively) and T2 values (71ms, 55ms and 53ms at presentation, 2 and 20 weeks respectively) demonstrated gradual resolution of myocardial oedema.
Learning Points from this
Case: Eosinophilic myocarditis is rare but life-threatening acute inflammatory disease of the heart. Less than 200 cases with histologically proven eosinophilic myocarditis have been published. This case demonstrates the role of CMR in diagnosis and illustrates the clinical course of the disease with its imaging correlates.