For the love of loeffler
Gindi R, Parikh S. For the love of loeffler. J Am Coll Cardiol. Mar 2017;69(11):2348-2348.
J Am Coll Cardiol
Background: Loeffler (Eosinophilic) endocarditis is a rare disease in which eosinophils infiltrate and damage theendocardium, leading to intense inflammation, thrombus formation and ultimately endocardial fibrosis. Stroke may be a presenting symptom. Multimodality imaging facilitates accurate diagnosis and appropriate treatment. Case: A 70-year-old male with a past medical history significant forprostate cancer in remission presented to his primary care provider with a complaint of left-sided weakness and ipsilateral facial droop. Labs on presentation revealed a significant troponin elevation concerning for an acute coronary syndrome. A brain MRI was performed and revealed bilateral strokes with concern for cardioembolic origin. An echocardiogram was performed and revealed normal left ventricular function, however was notable for a fixed mass on the lateral wall of the ventricle, measuring 35 mm x 16 mm. Decision-Making: Contrast enhanced echocardiography was used to narrow the differential as likely thrombus. Explanation for a large lateral wall thrombus was limited considering no wall motion abnormality, pseudoaneurysm, or evidence of infection. On review of records the patient was noted to have peripheral eosinophilia (8000 cells/uL) with levels greater than 2000 cells/uL for one year prior, raising concern for Loefflerendocarditis. Endocardial biopsy is the gold-standard fordiagnosis, however risks of the procedure were considered too high. A cardiac MRI was performed revealing diffuse abnormal subendocardial delayed enhancement with corresponding T2 signal hyperintensity, as well as superimposed non-enhancing thrombus, consistent with eosinophilic infiltration and superimposed thrombus. A decision was made to treat with high-dose steroids and systemic anticoagulation. Follow-up echocardiogram 6 months later revealed near complete resolution of themass. Conclusions: This case highlight's stroke as a presenting symptom in patients with Loeffler's endocarditis. Multimodality imaging, lab-work and thepatient's response to treatment cemented the diagnosis. Rapid diagnosis and treatment are vital as advanced stages have very high morbidity and mortality.