This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Yamaguchi, T. Articles by Yamagishi, M. Search for Related Content PubMed PubMed Citation Articles by Yamaguchi, T. Articles by Yamagishi, M. Related Collections Myocardial cardiomyopathy disease Nuclear cardiology and PET

(Circulation. 2000;102:2019.)
© 2000 American Heart Association, Inc.

Images in Cardiovascular Medicine

Dual SPECT Imaging of Löffler’s Endomyocarditis in the Acute Phase

Tomoyuki Yamaguchi, MD; Yoshio Yasumura, MD; Satoshi Nakatani, MD; Noritoshi Nagaya, MD; Hatsue Ishibashi-Ueda, MD; Masayuki Inubushi, MD; Yoshio Ishida, MD; Masakazu Yamagishi, MD

From the Divisions of Cardiology (T.Y., Y.Y., S.N., N.N., M.Y.), Pathology (H.I.-U.), and Radiology (M.I., Y.I.), National Cardiovascular Center, Osaka, Japan.

Correspondence to Masakazu Yamagishi, MD, FACC, Division of Cardiology, National Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka 565-8565, Japan. E-mail myamagi{at}hsp.ncvc.go.jp

A72-year-old man with bronchial asthma and atrial fibrillation was admitted to our clinic because of dyspnea. There had been no cardiac symptoms until 6 days earlier, when he noticed mild dyspnea that had developed rapidly. A chest radiograph showed pulmonary congestion. The ECG demonstrated significant ST-segment depression in leads V₂ to V₅, which suggested subendocardial ischemia. Blood analysis revealed a marked increase in total white blood cell (21 720/mm³) and eosinophil (9122/mm³) counts. The creatine kinase-MB level of 41 U/L suggested myocardial damage. By echocardiography, the thicknesses of the left ventricular septum and posterior wall were 11 and 12 mm, respectively; systolic wall motion was preserved. Although myocardial scintigraphy with ²⁰¹Tl showed no apparent image defect (Figure 1A), positive myocardial accumulation of ^99mTc pyrophosphate was clearly demonstrated (Figure 1B). From image fusion of the midventricular short-axis tomograms obtained by the dual image acquisition, this accumulation appeared to localize mainly in the whole endomyocardial layer except in the lateral wall, where the hot tracer distributed transmurally (Figure 1C). These findings were compatible with the histological findings in endomyocardial biopsy specimens taken from the ventricular septum during the acute phase. Prominent accumulation of eosinophils in the edematous endocardium and sporadic damage of myocytes with slight eosinophil infiltration in the subendomyocardial layer were observed (Figure 2). There was no evidence of necrotizing vasculitis. The diagnosis was Löffler’s endomyocarditis associated with hypereosinophilic syndrome.¹ Prednisolone (40 mg/d) dramatically improved the patient’s condition and lowered the number of peripheral eosinophils. The observed findings are somewhat similar to those of hypersensitivity myocarditis.² In these conditions, dual SPECT imaging during the acute phase can demonstrate the endomyocarditis.

View larger version (23K): [in this window] [in a new window]   Figure 1. SPECT images showing (A) no apparent image defect with 201Tl, (B) positive accumulation of 99mTc pyrophosphate, and (C) its endocardial accumulation by the dual image acquisition. Ant indicates anterior; Sep, septal; Lat, lateral; and Inf, inferior.

View larger version (97K): [in this window] [in a new window]   Figure 2. Accumulation of eosinophils in the endocardium and sporadic damage of myocytes with slight eosinophil infiltration in the subendocardial layer (hematoxylin-eosin staining; magnification x25 and x50).

Acknowledgments

The reproduction of color illustrations was supported by a grant from the Ministry of Heath and Welfare of Japan (to Dr Yamagishi)

Footnotes

The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.

Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.

References

1. Olsen EG, Spry CJ. Relation between eosinophilia and endomyocardial disease. Prog Cardiovasc Dis. 1985;27:241–254.[Medline] [Order article via Infotrieve]
   
2. Fenoglio JJ Jr, McAllister HA Jr, Mullick FG. Drug related myocarditis, I: hypersensitivity myocarditis. Hum Pathol.. 1981;12:900–907.[Medline] [Order article via Infotrieve]
   

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Yamaguchi, T. Articles by Yamagishi, M. Search for Related Content PubMed PubMed Citation Articles by Yamaguchi, T. Articles by Yamagishi, M. Related Collections Myocardial cardiomyopathy disease Nuclear cardiology and PET