1. Therapeutic Role of Pericardiocentesis for Acute Necrotizing Eosinophilic Myocarditis With Cardiac Tamponade 
Ryu Kazama, MD, Yuji Okura, MD, Makoto Hoyano, MD, Ken Toba, MD, Yukie Ochiai, MD, Noriko Ishihara, MD, Takashi Kuroha, MD, Tsuyoshi Yoshida, MD, Osamu Namura, MD, Masakazu Sogawa, MD, Yuichi Nakamura, MD, Nobuhiko Yoshimura, MD, Ken Nishikura, MD, Kiminori Kato, MD, Haruo Hanawa, MD, Yusuke Tamura, MD, Shinichiro Morimoto, MD, Makoto Kodama, MD, Yoshifusa Aizawa, MD 
Mayo Clinic Proceedings 
Volume 78, Issue 7, Pages (July 2003)
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2. Figure 1
Left, The electrocardiogram on admission showed mild (1-mm) ST-segment elevation in the inferior lead, lead I, and aVL lead. More prominent (2-mm) elevation was shown across precordial leads V2 through V6 and across lateral and anterior leads. Q waves were present in leads I, V5, and V6. PR-segment deviations were absent. Right, Electrocardiogram 3 weeks after admission showed R-wave recovery in leads V5 and V6 and R-wave augmentation in precordial leads. Negative T waves appeared in leads I, aVL, V5, and V6.
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3. Figure 2
Histopathologic specimens show a damaged myocardium. Top, Diffuse myocyte necrosis associated with infiltration of eosinophils and lymphocytes. A slight hemorrhage is also present (hematoxylin-eosin, original magnification ×40). Bottom, Eosinophils represented by segmented nuclei and eosinophilic granules. Some eosinophils showed degenerated features, and eosinophilic granules were observed in the interstitium (hematoxylin-eosin, original magnification ×100).
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4. Figure 3
Immunohistochemical specimens show localization of eosinophilic granule major basic protein (MBP) in endomyocardial biopsy specimen. Upper left, Endocardial thickening; MBP-positive granules were present in the layers of thickening endocardium in the absence of intact eosinophils. Upper right, An intact eosinophil (arrow) with MBP beneath a layer of endothelium. Endocardial thickening in this section was milder than that in upper left. Lower left, Eosinophils with MBP infiltrating into the interstitium of the myocardium. Myocyte necrosis was mild. Lower right, Adhesion of eosinophil to the endothelium (arrow).
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5. Figure 4
Clinical course: eosinophil count in peripheral blood peaked 2 weeks after the patient was admitted and decreased gradually to a normal level. Serum level of eosinophilic cationic protein (ECP) showed a simultaneous surge; however, C-reactive protein (CRP) peaked much earlier. Creatine kinase (Ck) increased on admission and normalized afterward. WBC = white blood cell count.
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6. Figure 5
Magnetic resonance images (short axis view) after gadolinium-DTPA injection. Left, Two weeks after patient was admitted, there was a late hyperenhancement (arrows) at the left ventricular septum and anterior wall. Gradient-echo images revealed reduced motion at the same site. Right, Five weeks after patient was admitted, neither enhancement nor wall motion abnormalities were observed.
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7. Figure 6
Cytokine levels in both pericardial effusion and blood serum were measured simultaneously during the virulent phase. Interleukin (IL) 5 and IL-13 levels were extremely high in pericardial effusion; IL-5 was also high in peripheral blood at onset of pericardial drainage. The IL-5 and IL-13 levels decreased 5 days after the patient was admitted. s-ICAM-1 = soluble-intercellular adhesion molecule-1; TGF-β1 = transforming growth factor-β1.
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