Aortic regurgitation and Churg-Strauss syndrome

Sir, A 56-year-old lady who was a lifelong non-smoker was admitted with acute pulmonary oedema. Echocardiography revealed severe aortic valve regurgitation and a left ventricular ejection fraction of 35–40% associated with moderate left ventricular dysfunction. Coronary angiography confirmed aortic regurgitation, as well as 60% stenosis in the left anterior descending artery with diffuse disease of the distal vessel. Three years earlier, she had been diagnosed with systemic hypertension and was prescribed an angiotensin-converting-enzyme inhibitor. Two months prior to this admission, she was admitted acutely with left ventricular failure and complete heart block, successfully managed with diuretics and insertion of a dual chamber permanent pacemaker. A clinical diagnosis of Churg-Strauss syndrome had been made 20 years earlier, based on severe asthma, sinusitis, marked peripheral eosinophilia, and mononeuritis multiplex involving her legs and hands. She improved following a 2-year course of tapered steroids and azathioprine, although she still suffered from residual numbness in both hands. Since then, she had required intermittent steroid therapy for asthma exacerbations, although peripheral blood eosinophilia was not a feature. She denied ever taking a leukotriene receptor antagonist.