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The cardiac valves showed no significant morphological or functional abnormalities&#46; There was pericardial thickening&#44; with a moderate circumferential effusion &#40;12<span class="elsevierStyleHsp" style=""></span>mm in parasternal long-axis view&#41;&#44; but no hemodynamic compromise &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was hospitalized on July 14&#44; 2008 with a diagnosis of myopericarditis&#46; Treatment was begun with aspirin in anti-inflammatory doses and opioid analgesics&#44; which brought some pain relief&#46; Laboratory tests showed a reduction in troponin I&#44; CRP and BNP levels&#44; while TTE showed reduced pericardial effusion and persistence of pericardial thickening&#46; Given her persistently high eosinophil count&#44; even for a patient with asthma&#44; and the coexistence of a left pleural effusion&#44; other diagnostic hypotheses besides acute viral myopericarditis included&#58; &#40;a&#41; recurrence of pulmonary tuberculosis&#44; &#40;b&#41; helminthiasis&#44; &#40;c&#41; hypereosinophilic syndrome&#44; and &#40;d&#41; Churg-Strauss syndrome&#46; Immunological study including ANA&#44; ANCA and rheumatoid factors was negative&#59; direct examination of expectoration was negative for BK virus&#59; stool cultures were negative for eggs&#44; cysts and parasites&#44; as was serology for CMV IgM&#44; EBV and herpes simplex 1 and 2 antibodies&#44; influenza A and B&#44; adenovirus&#44; echovirus and Coxsackie virus&#46; Thoracic computed tomography showed a small left pleural effusion&#46; The patient was discharged on July 16&#44; 2008&#44; reporting only mild left back pain on breathing deeply and medicated with aspirin 1000<span class="elsevierStyleHsp" style=""></span>mg every eight hours&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Ten days after discharge&#44; the patient experienced recurrence of chest pain&#44; with no fever&#46; Control TTE showed RV apical hypokinesia and an apical mass of the same signal intensity as the myocardium with no cleavage plane between the mass and the myocardial wall &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; Pericardial thickening persisted with a moderate effusion&#46; In the light of the new findings&#44; the RV mass was considered to be a thrombus or tumor&#44; or to be secondary to hypereosinophilic syndrome&#46; Oral anticoagulation with warfarin was begun given the suspicion of a thrombus and the patient was transferred to Coimbra University Hospital for cardiac magnetic resonance imaging &#40;CMRI&#41; and endomyocardial biopsy &#40;EMB&#41;&#46; CMRI revealed marked thickening of the RV apex&#44; of infiltrative appearance &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; Delayed enhancement showed heterogeneous areas of hyperintense signal in the RV apex&#44; septal wall and LV apex&#44; some of which had a subepicardial distribution&#46; EMB revealed fragmentation of muscle bundles by eosinophils&#44; with myocyte destruction and coagulation necrosis&#44; compatible with eosinophilic endocarditis&#46; The diagnosis of Loeffler&#39;s endocarditis was therefore established and treatment begun with oral prednisolone &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41;&#44; anticoagulation with warfarin being continued&#46; During follow-up&#44; the patient was completely free of pain&#44; her eosinophil count normalized and the RV myocardial thickening disappeared &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#44; confirmed by CMRI &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>&#41;&#46; Anticoagulation was maintained for three months and corticosteroid therapy for six months&#46; She subsequently had one episode of sustained back pain without hypereosinophilia or echocardiographic alterations&#44; and was treated with corticosteroids for four weeks&#46; The patient has been evaluated every six months by ECG&#44; laboratory tests and TTE&#44; and three years after beginning treatment&#44; control CMRI shows her to be in complete remission&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">In the case presented&#44; the possibility of Loeffler&#39;s endocarditis was considered given that the patient had eosinophilia and a mass in the RV apex&#44; which CRMI showed to be a myocardial infiltrate&#44; the diagnosis being confirmed by EMB&#46; Besides asthma&#44; which is not usually associated with such high eosinophil counts&#44; hypereosinophilia can have many causes&#44; the most common being autoimmune disease&#44; rheumatoid arthritis&#44; parasitic infection and eosinophilic leukemia&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Immunological study performed during the patient&#39;s first hospitalization excluded the first two hypotheses&#46; She had no contact with animals and had not recently traveled abroad&#44; no causative agent was isolated from stool cultures&#44; and clinical improvement was observed with anti-inflammatory drugs&#44; thus excluding parasitic infection&#46; No bone marrow biopsy was performed to exclude eosinophilic leukemia&#44; but the improvement observed with corticosteroid therapy does not support this hypothesis&#46; Although ideally treatment should be directed at the cause of hypereosinophlia&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> when there is no etiological diagnosis&#44; studies have shown regression of myocardial infiltrate with corticosteroids&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Warfarin was initially maintained due to the association between Loeffler&#39;s endocarditis and embolic events&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The effect of anti-inflammatory and immunosuppressive therapy with corticosteroids and cytotoxic agents varies&#44; but cases of hypereosinophilic syndrome with acute manifestations tend to respond better&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> While prognosis is generally poor&#44; rapid resolution with corticosteroid therapy has been described&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Loeffler&#39;s endocarditis is a rare entity&#44; and TTE and CMRI play a crucial role in its diagnosis&#46; Ideally treatment should be directed at the cause of hypereosinophilia but this remains unknown in most cases&#44; resulting in poor prognosis&#46; The case presented shows that in some patients&#44; even without an etiologic diagnosis of eosinophilia&#44; the prognosis of Loeffler&#39;s endocarditis can be favorable if treatment is initiated early&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Loeffler&#39;s endocarditis is an acute form of primary restrictive cardiomyopathy&#46; We report the case of a young woman with pleuritic chest pain associated with fever and hypereosinophilia&#46; She was hospitalized with suspected acute myopericarditis and was treated with aspirin&#44; leading to clinical improvement&#46; Ten days after discharge&#44; she was rehospitalized due to recurrence of chest pain&#46; The echocardiogram showed what appeared to be a mass filling the apex of the right ventricle &#40;RV&#41;&#46; She was referred for magnetic resonance imaging&#44; which revealed marked myocardial thickening in the apex of the RV&#46; The patient underwent an endomyocardial biopsy&#44; resulting in a diagnosis of eosinophilic endocarditis&#46; After treatment with prednisolone&#44; all symptoms and the eosinophilia disappeared&#44; and there was complete remission of the RV abnormalities&#46; After three years of follow-up&#44; the patient remains asymptomatic&#46; This case shows that&#44; even without an etiologic diagnosis of eosinophilia&#44; the prognosis for Loeffler&#39;s endocarditis can be favorable if treatment is initiated early&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A endomiocardite de L&#246;ffler &#233; uma miocardiopatia restritiva prim&#225;ria aguda&#46; Relatamos o caso cl&#237;nico de uma jovem que inicia dor tor&#225;cica pleur&#237;tica associada a febre e hipereosinofilia&#46; Internada por suspeita de miopericardite aguda e submetida a tratamento com &#225;cido acetilsalic&#237;lico&#44; verificou-se melhoria cl&#237;nica&#46; Dez dias ap&#243;s a alta &#233; reinternada por recorr&#234;ncia da dor&#46; O ecocardiograma mostrou uma aparente massa ocupando o apex do ventr&#237;culo direito &#40;VD&#41;&#46; Referenciada para resson&#226;ncia magn&#233;tica card&#237;aca&#44; esta demonstrou um marcado espessamento do mioc&#225;rdio no apex do VD&#46; Foi submetida a bi&#243;psia endomioc&#225;rdica que diagnosticou uma endomiocardite eosinof&#237;lica&#46; Ap&#243;s o in&#237;cio do tratamento com prednisolona&#44; verificou-se o desaparecimento da sintomatologia&#44; da eosinofilia e uma regress&#227;o completa das altera&#231;&#245;es no VD&#46; Ao fim de 3 anos de seguimento mant&#233;m-se assintom&#225;tica&#46; O caso descrito revela que o progn&#243;stico da endomiocardite de L&#246;ffler&#44; mesmo sem um diagn&#243;stico etiol&#243;gico da eosinofilia&#44; poder&#225; ser favor&#225;vel&#44; se o tratamento for iniciado precocemente&#46;</p>"
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Case report
Loeffler's endocarditis—A case report
Endomiocardite de Löffler – a propósito de um caso clínico
Ricardo Faria
Corresponding author
ricardofaria555@gmail.com

Corresponding author.
, Walter Santos, Vasco Marques, Nuno Marques, Nelson Tavares, Veloso Gomes
Serviço de Cardiologia, Hospital de Faro, Faro, Portugal
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with no fever&#46; Control TTE showed RV apical hypokinesia and an apical mass of the same signal intensity as the myocardium with no cleavage plane between the mass and the myocardial wall &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; Pericardial thickening persisted with a moderate effusion&#46; In the light of the new findings&#44; the RV mass was considered to be a thrombus or tumor&#44; or to be secondary to hypereosinophilic syndrome&#46; Oral anticoagulation with warfarin was begun given the suspicion of a thrombus and the patient was transferred to Coimbra University Hospital for cardiac magnetic resonance imaging &#40;CMRI&#41; and endomyocardial biopsy &#40;EMB&#41;&#46; CMRI revealed marked thickening of the RV apex&#44; of infiltrative appearance &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; Delayed enhancement showed heterogeneous areas of hyperintense signal in the RV apex&#44; septal wall and LV apex&#44; some of which had a subepicardial distribution&#46; EMB revealed fragmentation of muscle bundles by eosinophils&#44; with myocyte destruction and coagulation necrosis&#44; compatible with eosinophilic endocarditis&#46; The diagnosis of Loeffler&#39;s endocarditis was therefore established and treatment begun with oral prednisolone &#40;1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day&#41;&#44; anticoagulation with warfarin being continued&#46; During follow-up&#44; the patient was completely free of pain&#44; her eosinophil count normalized and the RV myocardial thickening disappeared &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#44; confirmed by CMRI &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>&#41;&#46; Anticoagulation was maintained for three months and corticosteroid therapy for six months&#46; She subsequently had one episode of sustained back pain without hypereosinophilia or echocardiographic alterations&#44; and was treated with corticosteroids for four weeks&#46; The patient has been evaluated every six months by ECG&#44; laboratory tests and TTE&#44; and three years after beginning treatment&#44; control CMRI shows her to be in complete remission&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">In the case presented&#44; the possibility of Loeffler&#39;s endocarditis was considered given that the patient had eosinophilia and a mass in the RV apex&#44; which CRMI showed to be a myocardial infiltrate&#44; the diagnosis being confirmed by EMB&#46; Besides asthma&#44; which is not usually associated with such high eosinophil counts&#44; hypereosinophilia can have many causes&#44; the most common being autoimmune disease&#44; rheumatoid arthritis&#44; parasitic infection and eosinophilic leukemia&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Immunological study performed during the patient&#39;s first hospitalization excluded the first two hypotheses&#46; She had no contact with animals and had not recently traveled abroad&#44; no causative agent was isolated from stool cultures&#44; and clinical improvement was observed with anti-inflammatory drugs&#44; thus excluding parasitic infection&#46; No bone marrow biopsy was performed to exclude eosinophilic leukemia&#44; but the improvement observed with corticosteroid therapy does not support this hypothesis&#46; Although ideally treatment should be directed at the cause of hypereosinophlia&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> when there is no etiological diagnosis&#44; studies have shown regression of myocardial infiltrate with corticosteroids&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Warfarin was initially maintained due to the association between Loeffler&#39;s endocarditis and embolic events&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The effect of anti-inflammatory and immunosuppressive therapy with corticosteroids and cytotoxic agents varies&#44; but cases of hypereosinophilic syndrome with acute manifestations tend to respond better&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> While prognosis is generally poor&#44; rapid resolution with corticosteroid therapy has been described&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Loeffler&#39;s endocarditis is a rare entity&#44; and TTE and CMRI play a crucial role in its diagnosis&#46; Ideally treatment should be directed at the cause of hypereosinophilia but this remains unknown in most cases&#44; resulting in poor prognosis&#46; The case presented shows that in some patients&#44; even without an etiologic diagnosis of eosinophilia&#44; the prognosis of Loeffler&#39;s endocarditis can be favorable if treatment is initiated early&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Loeffler&#39;s endocarditis is an acute form of primary restrictive cardiomyopathy&#46; We report the case of a young woman with pleuritic chest pain associated with fever and hypereosinophilia&#46; She was hospitalized with suspected acute myopericarditis and was treated with aspirin&#44; leading to clinical improvement&#46; Ten days after discharge&#44; she was rehospitalized due to recurrence of chest pain&#46; The echocardiogram showed what appeared to be a mass filling the apex of the right ventricle &#40;RV&#41;&#46; She was referred for magnetic resonance imaging&#44; which revealed marked myocardial thickening in the apex of the RV&#46; The patient underwent an endomyocardial biopsy&#44; resulting in a diagnosis of eosinophilic endocarditis&#46; After treatment with prednisolone&#44; all symptoms and the eosinophilia disappeared&#44; and there was complete remission of the RV abnormalities&#46; After three years of follow-up&#44; the patient remains asymptomatic&#46; This case shows that&#44; even without an etiologic diagnosis of eosinophilia&#44; the prognosis for Loeffler&#39;s endocarditis can be favorable if treatment is initiated early&#46;</p>"
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        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A endomiocardite de L&#246;ffler &#233; uma miocardiopatia restritiva prim&#225;ria aguda&#46; Relatamos o caso cl&#237;nico de uma jovem que inicia dor tor&#225;cica pleur&#237;tica associada a febre e hipereosinofilia&#46; Internada por suspeita de miopericardite aguda e submetida a tratamento com &#225;cido acetilsalic&#237;lico&#44; verificou-se melhoria cl&#237;nica&#46; Dez dias ap&#243;s a alta &#233; reinternada por recorr&#234;ncia da dor&#46; O ecocardiograma mostrou uma aparente massa ocupando o apex do ventr&#237;culo direito &#40;VD&#41;&#46; Referenciada para resson&#226;ncia magn&#233;tica card&#237;aca&#44; esta demonstrou um marcado espessamento do mioc&#225;rdio no apex do VD&#46; Foi submetida a bi&#243;psia endomioc&#225;rdica que diagnosticou uma endomiocardite eosinof&#237;lica&#46; Ap&#243;s o in&#237;cio do tratamento com prednisolona&#44; verificou-se o desaparecimento da sintomatologia&#44; da eosinofilia e uma regress&#227;o completa das altera&#231;&#245;es no VD&#46; Ao fim de 3 anos de seguimento mant&#233;m-se assintom&#225;tica&#46; O caso descrito revela que o progn&#243;stico da endomiocardite de L&#246;ffler&#44; mesmo sem um diagn&#243;stico etiol&#243;gico da eosinofilia&#44; poder&#225; ser favor&#225;vel&#44; se o tratamento for iniciado precocemente&#46;</p>"
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ISSN: 21742049
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Revista Portuguesa de Cardiologia (English edition)
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By checking that you are a health professional, you are stating that you are aware and accept that the Portuguese Journal of Cardiology (RPC) is the Data Controller that processes the personal information of users of its website, with its registered office at Campo Grande, n.º 28, 13.º, 1700-093 Lisbon, telephone 217 970 685 and 217 817 630, fax 217 931 095, and email revista@spc.pt. I declare for all purposes that the information provided herein is accurate and correct.