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Cardiovascular Disease |

Atypical Chest Pain as a Presenting Symptom of Eosinophilic Granulomatosis With Polyangiitis

Andreea Nitu-Marquise, MD; Vanessa Hoy, MD; Omar Mousa, MD
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SUNY Upstate, Syracuse, NY


Chest. 2013;144(4_MeetingAbstracts):153A. doi:10.1378/chest.1704063
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Abstract

SESSION TITLE: Cardiovascular Student/Resident Case Report Posters II

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Cardiac involvement in eosinophilic granulomatosis with polyangiitis (EGPA), also known as Churg-Strauss Syndrome, has variable presentations. EGPA induced cardiomyopathies (EGPAIC) is a major cause of mortality, leading to 50% of deaths in such patients. This serves as an important prognostic factor. We present EGPA, initially presenting as acute coronary syndrome (ACS) and review the current literature and management.

CASE PRESENTATION: A 59 year-old Caucasian female, with a known history of asthma and dyslipidemia, presented with atypical chest pain, shortness of breath, and left leg pain for two weeks. She was seen by her primary care provider prior to presentation for the left leg pain, and had no evidence of deep venous thrombosis. Her physical exam was remarkable for tachycardia and left lower extremity weakness. Initial laboratory investigations were significant for elevated troponins and eosinophilia (35%). The chest X-ray showed perihilar opacities and small bilateral pleural effusions. Electrocardiography showed sinus tachycardia. The patient underwent transthoracic echocardiography, which showed findings compatible with early cardiac tamponade. A cardiac magnetic resonance imaging showed a left ventricular ejection fraction of 36% with a small circumferential pericardial effusion and mid-wall fibrosis involving the distal inferior septum. Electromyography revealed mononeuritis multiplex. According to the American College of Rheumatology, the patient met 4 of the 6 criteria required for diagnosis of EGPA. The patient was started on aspirin and high doses of solumederol, and subsequently transitioned to oral prednisone and azathioprine. The patient recovered with immunosuppressant therapy and had close follow up with Rheumatology.

DISCUSSION: As we presented in this case, the initial presentation of EGPA may be atypical chest pain imitating ACS. However, significant eosinophilia raised our suspicion. Extensive cardiac workup was completed and other etiologies were ruled out. Endomyocardial biopsy was not completed in this case as the precedence of treatment outweighed the risk of the procedure. Patients should have close follow up upon initiation of immunosuppressant therapy.

CONCLUSIONS: EGPAIC reflects the disease severity and imposes early recognition and treatment. Such approach is imperative, as cardiac manifestations serves amongst the strongest predictors of poor prognosis, with a high mortality rate.

Reference #1: Neumann T, Manger B, et al. Cardiac Involvement in Churg-Strauss Syndrome. Impact of Endomyocarditis. Medicine. 2009; 88: 236-243.

Reference #2: Aakeroy L, Amundsen B, et al. A 50-year-old man with eosinophilia and cardiomyopathy: need for endomyocardial biopsy. EJE. 2011; 12: 257-259.

Reference #3: Rigamonti F, De Benedetti E, et al. Cardiac involvement in Churg-Strauss syndrome mimicking acute coronary syndrome. Swiss Med Wkly. 2012;142: w13543.

DISCLOSURE: The following authors have nothing to disclose: Andreea Nitu-Marquise, Vanessa Hoy, Omar Mousa

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