Multiple brain infarctions and endomyocarditis in ANCA-negative eosinophilic granulomatosis with polyangiitis.

Eosinophilic granulomatosis with polyangiitis (EGPA) is a small vessel necrotizing vasculitis characterized by asthma and eosinophilia. Ischemic stroke is a rare complication of the disease. We herein report a case involving a 77-year-old woman with sinusitis who developed embolic stroke and splenic infarctions. Laboratory tests revealed hypereosinophilia and elevated troponin-T and N-terminal pro-brain natriuretic peptide. Antineutrophil cytoplasmic antibodies (ANCA) studies were negative. Skin biopsy showed infiltration of eosinophils into the arterial walls. These clinicopathological findings led to the diagnosis of EGPA. We also found the evidence of endomyocarditis as revealed by multimodality cardiac imaging. The patient underwent continuous immunosuppressive and anticoagulation therapy, and the infarctions did not recur. This report highlights the importance of histologically proven vasculitis with eosinophil infiltration and careful examination for cardiac involvement, especially in ANCA-negative patients.

Fulminant myocarditis spreading from the right ventricle treated with extracorporeal membrane oxygenation and impella.

Although the pathogenesis of fulminant myocarditis varies, it is usually recognised by symptoms such as chest pain or syncope, echographic findings such as abnormal left ventricular (LV) wall motion, elevated cardiac enzymes and arrhythmias. We encountered a case of acute myocarditis with syncope, electrocardiographic changes suggestive of coronary artery disease in the inferior wall with abnormal wall motion in the right ventricle, which eventually developed into fulminant disease. Multidetector CT showed a contrast effect localised to the right ventricle in the late-contrast phase, suggesting a right ventricular myocardial injury. Thereafter, the LV function rapidly decreased. Finally, mechanical circulatory support with extracorporeal membrane oxygenation and an intra-aortic balloon pump was needed. A myocardial biopsy of the right ventricular septum showed severe degenerative findings such as myocyte tearing and segmentation with infiltration of inflammatory cells including lymphocytes. After insertion of an Impella pump, the right ventricular function gradually improved.