Loeffler endocarditis with intracardiac thrombus: case report and literature review

Background Loeffler endocarditis is a relatively rare and potentially life-threatening heart disease. This study aimed to identify the characteristic features of Loeffler endocarditis with intracardiac thrombus on a background of hypereosinophilic syndrome (HES). Case presentation We described a 57-year-old woman with Loeffler endocarditis and intracardiac thrombus initially presenting with neurological symptoms, who had an embolic stroke in the setting of HES. After cardiac magnetic resonance (CMR), corticosteroids and warfarin were administered to control eosinophilia and thrombi, respectively. During a 10-month follow-up, the patient performed relatively well, with no adverse events. We also systematically searched PubMed and Embase for cases of Loeffler endocarditis with intracardiac thrombus published until July 2021. A total of 32 studies were eligible and included in our analysis. Further, 36.4% of recruited patients developed thromboembolic complications, and the mortality rate was relatively high (27.3%). CMR was a powerful noninvasive modality in providing diagnostic and follow-up information in these patients. Steroids were administered in 81.8% of patients, achieving a rapid decrease in the eosinophil count. Also, 69.7% of patients were treated with anticoagulant therapy, and the thrombus was completely resolved in 42.4% of patients. Heart failure and patients not treated with anticoagulation were associated with poor outcomes. Conclusions Cardiac involvement in HES, especially Loeffler endocarditis with intracardiac thrombus, carries a pessimistic prognosis and significant mortality. Early steroids and anticoagulation therapy may be beneficial once a working diagnosis is established. Further studies are needed to provide evidence-based evidence for managing this uncommon manifestation of HES.

Contrast-Enhanced Echocardiography Imaging With a Noncontrast MRI Technique Used in a Patient With Chronic Kidney Disease to Diagnose Loeffler Endocarditis

Loeffler endocarditis is rare and can initially be a clinically silent cardiac disorder. Given its natural history with evolving stages and its vague initial cardiac presentation, it is important to keep this as a differential diagnosis. Without treatment, this disorder is progressive and may lead to a possible restrictive cardiomyopathy-related heart failure. Here, a rare case who presented with nonspecific chest pain is reported, which was recognized early by a routine noninvasive transthoracic echocardiography (TTE) imaging study. This was followed by the addition of contrast enhancement techniques, which made it possible to solidify the diagnosis of the mass to a right ventricular thrombus (possibly secondary to the hypereosinophilia syndrome), with isolated right ventricular involvement. Magnetic resonance imaging (MRI) of the heart, without contrast, was performed to further analyze the anatomic location of this entity. A high index of suspicion for Loeffler endocarditis helped identify this condition.

P1685 Loeffler endocarditis mimicking myocardial infarction

Loeffler endocarditis is a major cause of morbidity and mortality in patient with hypereosinophilia-associated syndromes. It is a rare disease that occurs due to eosinophilic inflammation of the endocardium with fibrosis and thrombus formation. We describe a case of Loeffler endocarditis with unusual clinical course. 61-year-old woman was admitted due to chest pain and elevated troponin I level. Her past medical history was remarkable for persistent asthma, rhinitis, and productive cough for almost 1 year. Laboratory test revealed hypereosinophilia. Further workup for parasitic diseases, allergy, malignancy, hematological causes were all negative Coronary angiography excluded coronary artery disease. Transthoracic echocardiography (TEE) showed endocardium thickening at the septal left ventricular wall, diastolic dysfunction (Grade II), and moderate pericardial effusion (Figure 1A). Cardiac magnetic resonance imaging (cMR) confirmed endocardial inflammation. The Loeffler endocarditis was diagnosed and corticosteroid treatment was started. After one year the patient was asymptomatic, TEE showed improvement of left ventricular diastolic function (Grade I) and complete regression of myocardial thickening (Figure 1B). Therefore, corticosteroids were slowly tapered. After 16 months she relapsed with severe chest pain, marked eosinophilia and elevated troponin I level. Left ventricular systolic function rapidly deteriorated to ejection fraction of 40%. Urgent cMR showed diffuse edomyocardial inflammation with apical thrombus formation. She was immediately treated with high doses of corticosteroid and heparin, which resulted in systolic function normalization and thrombus disappearance. In conclusion, Loeffer endocarditis still represents diagnostic challenge, may have unpredictable clinical course and generally respond well to corticosteroid treatment in early stages. Abstract P1685 Figure 1.