Successful Treatment of Acute Fulminant Eosinophilic Myocarditis in a Patient with Ulcerative Colitis Using Steroid Therapy and Percutaneous Cardiopulmonary Support

Figures

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  Figure 1.. Electrocardiogram (ECG) changes during admission. (A) ECG obtained on admission shows a sinus rhythm with a heart rate of 103 beats per minute, ST elevation in leads I, II, III, aVF, and V5-V6, and ST depression in leads V1-V2. (B) ECG performed on day 4 after admission shows complete left bundle branch brock (CLBBB) and intermittent I-III-degree atrioventricular (A-V) block intermittently. (C) ECG performed after recovery shows improvement in the poor R voltages and wide QRS. Abnormal Q waves in leads III, and aVF and inverted T wave in leads in II, III, aVF, and V6 remain.

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  Figure 2.. Left ventriculography (LVG) performed on admission and echocardiography (UCG) performed on day 3 after admission. (A) Left ventricle angiography showing a depressed left ventricular ejection fraction (LVEF) of 23.0% with diffuse hypokinesis, with paticulary severe inferior-to-posterior wall hypokinesis. (B) UCG on day 3 after admission showing that the left ventricular (LV) function was decreased, with an ejection fraction of 15%. Thickening of the LV wall can be seen.

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  Figure 3.. The clinical course of the acute phase. The CI and EF via two-dimensional echocardiography decreased after admission despite PCPS, IABP, and intravenous catecholamine infusion. The CI and EF improved with steroid treatment. LV dysfunction lasted until day 11 after admission; PCPS support was used for 15 days. The peripheral eosinophilia count is within the normal range. CI: cardiac index, EF: ejection fraction, WBC: leukocyte, Eosino: eosinophil, CK: creatine kinase, CPK-MB: creatine kinase-muscle/brain, PCPS: percutaneous cardiopulmonary support, IABP: intra-aortic balloon pumping, mPSL: methylprednisolone, PSL: prednisolone

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  Figure 4.. Chest radiography performed during admission. (A) Chest radiography performed on day 4 after admission showing cardiomegaly and progression of lung congestion. (B) Chest radiography performed after recovery showing a decrease in the cardiothoracic rate and the disappearance of lung congestion.

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  Figure 5.. Electrocardiography results. ECG showing monomorphic sustained ventricular tachycardia (VT) with a rate of 150 beats per minute on day 4 after admission. The patient’s blood pressure decreased to 40-50 mmHg with sustained VT. Electrical cardioversion (which was allowed in the present case) was needed to recover to sinus rhythm.

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  Figure 6.. Histological images of an endocardial biopsy. (A, B) Eosinophilia and lymphocyte infiltration and damage to the myocardial muscles (Hematoxylin and Eosin (H&E) staining) (A: ×100, B: ×400). (C, D) Infiltration of eosinophils and degranulation of eosinophil granules (C: H&E staining, ×600, D: direct fast scarlet stain, ×600).

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  Figure 7.. Left ventriculography (LVG) and echocardiography (UCG) performed after recovery. (A) LVG showing a left ventricular ejection fraction (LVEF) of 40.5% with severe inferior-to-posterior wall hypokinesis associated with aneurysmal changes. (B) UCG showing improvement in the LV function. Inferior to posterior wall hypokinesis remains associated with the thinning of the LV wall.