Cardiovascular Journal of Africa: Vol 31 No 2 (March/April 2020)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 31, No 2, March/April 2020 AFRICA e1
Case Report
Large left ventricular non-infectious vegetation in patient
with eosinophilic granulomatosis with polyangiitis
Yun-Seok Song, Sang-Hoon Seol, Jino Park, Dong-Kie Kim, Yeo-Jeong Song, Seunghwan Kim, Ki-Hun
Kim, Doo-Il Kim, Chan-Seon Park, Yeon-Mi Kim
Abstract
Eosinophilic granulomatosis with polyangiitis (EGPA) is a
rare form of systemic vasculitis in which cardiac involvement
is relatively common and accounts for half of EGPA-related
deaths. Cardiac involvement is more frequent in patients
with an absence of anti-neutrophil cytoplasmic antibody and
those with higher eosinophil counts. Clinical manifestations
are various, including myocarditis, pericarditis, pericardial
effusion, heart failure, arrhythmias, valvular insufficiencies
and intra-cardiac thrombus formation. The pathology of
cardiac involvement in EGPA is usually endomyocardial and
pericardial eosinophilic infiltration. Considering the poten-
tially adverse outcomes associated with cardiac involvement
in EGPA, early detection is important. We experienced a rare
case of EGPA with cardiac involvement presenting with non-
infectious vegetations.
Keywords: eosinophilic granulomatosis with polyangiitis (EGPA),
left ventricular non-infectious vegetation
Submitted 23/4/19, accepted 23/10/19
Published online
Cardiovasc J Afr 2020; 31: e1–e4
DOI: 10.5830/CVJA-2019-065
Case report
A 27-year-old man was transferred to our hospital after 10 days
of persistent fever, skin rash, and pain and numbness in both
ankles. At another hospital he had had antibiotic treatment
with ceftriaxone and doxycycline on the presupposition that it
was Tsutsugamushi disease, but it had no effect. The patient was
regularly followed up at the Department of Allergy and Clinical
Immunology for two years because of bronchial asthma and
chronic rhinitis.
On admission, his body temperature was 38.1°C, blood
pressure was 120/80 mmHg, heart rate was 80 beats/min,
and respiratory rate was 20 breaths/min. Breath sounds were
slightly decreased on the left lower lung field, and no heart
murmur was audible. Petechial rash was found on his whole
body. Electrocardiography was in normal sinus rhythm. A chest
radiograph showed blunted left costopleural angle and the
cardiac contour seemed to be slightly widened.
Initial laboratory tests showed mild leukocytosis (9.14 × 109
cells/l) with marked eosinophilia (39.0%). C-reactive protein
was 11.5mg/dl and the cardiac markers, pro-BNP (3548.0 pg/
ml), CK-MB (20.9 ng/ml) and troponin-I (2.92 ng/ml) were
elevated. On additional laboratory examination, perinuclear anti-
neutrophil cytoplasmic antibody (P-ANCA) and cytoplasmic
anti-neutrophil cytoplasmic antibody (C-ANCA) were negative.
Parasite-specific antibodies were all negative and total Ig E
level was high at 2154.0 IU/ml. Blood cultures were all negative.
The absence of platelet-derived growth factor receptor-α and
- β (PDGRFA, PDGFRB) gene fusion made a diagnosis of
idiopathic hyper-eosinophilic syndrome unlikely. A pleural
effusion study revealed neutrophil-predominant exudate, the pH
was 7.0, adenosine deaminase was 25 IU/l, glucose was 51 mg/
dl (2.83 mmol/l), and Gram and AFB staining were negative.
Bacterial and fungal cultures showed no growth.
Cardiac evaluation was performed because of the elevated
cardiac markers. Transthoracic echocardiography showed
oscillating mass-like lesions at the mid anteroseptal wall of the
left ventricle. The heart chamber size and left ventricular (LV)
wall thickness were in the normal range, and LV systolic and
diastolic function were normal (Fig. 1). There was no evidence
of pericardial effusion or inferior vena cava plethora. Coronary
angiographic computed tomography revealed a normal coronary
artery. Cardiac magnetic resonance imaging (MRI) was refused
for the reason that the patient had panic disorder.
For lower extremity numbness, a nerve conduction study
was performed, which showed decreased sensory nerve action
potential amplitude in both sural nerves. Intravenous methyl-
Department of Internal Medicine, Haeundae Paik Hospital,
Inje University College of Medicine, Busan, Korea
Yun-Seok Song, MD
Sang-Hoon Seol, MD,
Jino Park, MD
Dong-Kie Kim, MD
Yeo-Jeong Song, MD
Seunghwan Kim, MD
Ki-Hun Kim, MD
Doo-Il Kim, MD
Chan-Seon Park, MD
Department of Pathology, Haeundae Paik Hospital, Inje
University College of Medicine, Busan, Korea
Yeon-Mi Kim, MD