1. CHURG-STRAUSS SYNDROME AND EOSINOPHILIC ENDOCARDITIS
Anush Barkhudaryan, MD
Co-author: Dr. S. Grigoryan
Clinic of General and Invasive Cardiology,
University Hospital Complex № 1, Yerevan State Medical University after M. Heratsi, Armenia
October 7-13, 2012, Salzburg, Austria

2. PATIENT HISTORY
Patient S.E., 61 yrs. old female, had complains of asphyxia, spastic dry cough, sense of shortage of breath, dyspepsia for the past 2 years
Chest X-ray + full blood test (eosinophilia) → bronchial asthma (Euphyllin, 1 tabl. × 1/day, Seretide)
In August 2011, coronaroangiography for symptoms of chest pain → no significant narrowing of coronary vessels → the patient was discharged from the hospital.
Since September 2011, loss of weight /13 kgs in 1 year/, appetite and weakness
On , the episode of asthma - acute respiratory insufficiency /status asthmaticus/ → the patient was hospitalized.

3. PHYSICAL EXAMINATION Cardiovascular system Respiratory system
HR beats/min, BP 90/60-120/70 mm Hg, heart sounds are slightly muffled, the borders of relative cardiac dullness are within the norm
Respiratory system
Percussion of the lungs-pulmonary sound, auscultation - diffuse dry rales, crackles in posterior-inferior segments of the lungs
Gastrointestinal system
Abdomen is soft, nonpainful during palpation, liver is at the edge of costal arch
Urogenital system
Urination is free, nonpainful, Pasternacki's symptom is negative on both sides

4. LABORATORY EVALUATION AND DIAGNOSTIC PROCEDURES
Instrumental Methods
1. ECG
2. EchoCG
3. Tansesophageal Echo (to exclude hypertrophic CMP)
4. CT
Laboratory Tests
1. Full Blood Count
2. Biochemical Test
3. Immunological Analysis

5. ELECTROCARDIOGRAM (ECG)
ECG.-Sinus rhythm, HR-100 beats/min, left axis deviation, signs of LV hypertrophy, Ppulmonalae in leads II, III, aVF, ST segment depressions in leads V3-V6, -T waves in I II III, AVF and V4-V6.

6. THORACIC CT SCAN
The picture of interventricular thrombus (3.4 x 3.0 cm) in size: The hernia of the esophageal part of diaphragm is present which requires control by eshophagogastroscopy.

7. TRANSESOPHAGEAL ECHO An asymmetric hypertrophy of LV
LVEF=45-50%, hypokinesis of septal-apical, apical segments of LV
TAPSE = 2,1cm
LA is enlarged
A mixed thrombotic and eosinophilic mass in the apical part of LV-3.9x 2.8 cm in size.
The chordae of the posterior cusp of MV are also involved in this process.
Doppler Echo - diastolic dysfunction, mitral regurgitation I-II, tricuspid regurgitation I.
Summary - Atypical apical hypertrophic cardiomyopathy or fibroplastic endocarditis in hypereosinophilic syndrome

8. FULL BLOOD TEST Admission (21.06.12) Discharge (04.07.12) Normal range
WBC
5.92
8.30
x109/L
Band neutrophils
12 ↑
7 ↑ %
Neutrophil
granulocytes
41.4 ↓
72.0 %
Eosinophils
2.42↑
0.07
x109/L
Lymphocytes
12.8↓
18.8 %
RBC
3.24↓
3.43↓
x1012/L
Haematocrit
32.5↓
34.8↓ %
Thrombocytes
131↓
281
x109/L
ESR
50↑
20↑
mm/hr
Creatinine
107.5 ↑
μmol/L
Uric acid
345.1 ↑
µmol/L
CRP
24 ↑
< 12
Prothrombin Index
84.6
77.6 ↓ %
APTT
32.9
26-36 s
INR
1.14
1.22

9. LABORATORY TESTS FOR PARASITIC INFECTIONS
Type of Parasite/Antibodies
Result
Normal range
(U/mL)
Giardia lamblia/IgF, IgM, IgG/
Negative
< 1.0
Ascaris lumbricoides/IgG/
Echinococcus granulosus/IgG/
Toxocara canis/IgG/

10. IMMUNOLOGICAL TEST Types of Antibodies Result Normal range (U/mL)
Antinuclear antibodies (ANA)
0.3
< 1.0
Anti-SS-A (Ro) antibodies
2.1
< 15.0
Anti-RNP/Sm antibodies
3.4
Rheumatoid factor (RF)
neg.
<20
D-dimer
0.72 ↑
< 0.5 mg/L
ANCA
0.6
<1

11. THROMBOTIC AND EOSINOPHILIC MASS IN THE LV (ECHO, CT)
CLINICAL DIAGNOSIS
EOSINOPHILIA IN THE PATIENT’S BLOOD, BRONCHIAL ASTHMA ↓
THROMBOTIC AND EOSINOPHILIC MASS IN THE LV (ECHO, CT)
ACUTE RESPIRATORY INSUFFICIENCY III°. RESTRICTIVE CARDIOMYOPATHY: LOEFFLER’S HYPEREOSINOPHILIC SYNDROME /CHURG–STRAUSS SYNDROME, AUTOIMMUNE ENDOCARDITIS/. CIRCULATORY FAILURE II°.

12. TREATMENT Dexamethasone 12 mg Sol. NaCL 0.9 % - 100 ml × 1, i/v
× 1, i/v
Metypred 4.0 mg
6 tablets
Sol. Euphyllini 2.4 %- 5.0 ml
i/v,
Influcid® 
1 tab. × 1
Arixtra 2.5 mg
Furosemide 20 mg
Coraxane 5.0 mg
1 tab. × 2
Verospiron 25 mg
½ tab. × 1
Lercamen 10 mg
¼ tab. × 1

13. OUTCOME
The patient was treated in the Intensive Care Unit (ICU) for 2 weeks
Laboratory markers improved (thrombocytes↑, eosinophils↓, ESR↓,prothrombin↓)
LVEF increased to % due to free basal and middle segments of LV
Prednisolone, verospiron, lercamen, cardioaspirin and warfarin were prescribed
The patient was discharged on in a clinical satisfactory state
Control of protrombin, INR and EchoCG in dynamics were recommended.

14. THANK YOU FOR ATTENTION!