Magnetic Resonance Imaging in Löffler Endocarditis

A 72-year-old Japanese man was admitted with purpura, thrombocytopenia, and cough. Laboratory data were as follows: white blood cells, 9,900/mm³; eosinophils, 3,663/mm³ (37%); platelets, 22,000/mm³; D-dimer, 17.7 μg/mL; high-sensitivity troponin T, 0.022 ng/mL; C-reactive protein, 3.27 mg/dL; and N-terminal-probrain natriuretic peptide, 1,271 pg/mL. Electrocardiography was unremarkable. On echocardiography a trabecular appearance was noted in the apex of the left ventricle (LV; Supplementary Figure) with a normal LV ejection fraction without local asynergy. Contrast-enhanced chest computed tomography showed apical thrombus of the LV with bilateral pleural effusion (Supplementary Figure). Cardiac magnetic resonance imaging (CMRI) showed a trabecular thrombus and apical endocardial fibrosis (Figure A–C). First, idiopathic thrombocytopenic purpura was suspected and steroid pulse therapy was started with diuretics. Finally, the patient was diagnosed with hyper-eosinophilic syndrome at 3 weeks after admission. Endomyocardial biopsy was not performed because the patient did not agree.

Figure.

Initial cardiac magnetic resonance imaging (CMRI) showing (A) a trabecular appearance (arrowheads) and (B,C) late gadolinium enhancement of the endocardium in the left ventricle (LV) (arrows). (D) Repeated CMRI showing a typical apical thrombus of the LV (arrowheads) and (E,F) late gadolinium enhancement of the endocardium in the LV (arrows). (G–I) CMRI at 6 months after treatment showing disappearance of the apical thrombus, and improvement (albeit persistence) of the endocardial fibrosis (arrows).

CMRI showed mural thrombus and endocardial fibrosis at the apex of the LV, compatible with Löffler endocarditis (Figure D–F). The thrombus disappeared, and endocardial fibrosis improved but persisted at 6 months after treatment with prednisolone and warfarin (Figure G–I). There were no abnormal neurological findings.

CMRI is useful to diagnose Löffler endocarditis¹ and demonstrate its change.

Disclosures

The authors declare no conflicts of interest. K.M. is a member of Circulation Reports ’ Editorial Team.

Supplementary Files

Please find supplementary file(s);

http://dx.doi.org/10.1253/circrep.CR-19-0099

Reference

• 1.   Flanigan MJ, Velez MR, Ruden EA, Lilly SM. Löffler endocarditis and endomyocardial fibrosis. J Am Osteopath Assoc 2017; 117: 601.