Churg–Strauss syndrome presenting with eosinophilic myocarditis: A diagnostic challenge

array:24 ["pii" => "S0870255113001224" "issn" => "08702551" "doi" => "10.1016/j.repc.2012.10.017" "estado" => "S300" "fechaPublicacion" => "2013-09-01" "aid" => "293" "copyright" => "Sociedade Portuguesa de Cardiologia" "copyrightAnyo" => "2012" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2013;32:707-11" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 8166 "formatos" => array:3 [ "EPUB" => 199 "HTML" => 6855 "PDF" => 1112 ] ] "itemSiguiente" => array:19 [ "pii" => "S0870255113000814" "issn" => "08702551" "doi" => "10.1016/j.repc.2012.12.014" "estado" => "S300" "fechaPublicacion" => "2013-09-01" "aid" => "281" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2013;32:713-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 5742 "formatos" => array:3 [ "EPUB" => 193 "HTML" => 4274 "PDF" => 1275 ] ] "pt" => array:13 [ "idiomaDefecto" => true "cabecera" => "Caso Clínico" "titulo" => "Lesão tumoral gigante na aurícula esquerda: um caso incomum de sarcoma cardíaco indiferenciado" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "pt" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "713" "paginaFinal" => "716" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Giant tumoral lesion in the left atrium: An uncommon case of undifferentiated cardiac sarcoma" ] ] "contieneResumen" => array:2 [ "pt" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figura 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1050 "Ancho" => 1583 "Tamanyo" => 205280 ] ] "descripcion" => array:1 [ "pt" => "Imagem da lesão (após exérese cirúrgica da mesma)." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Catarina Ferreira, Daniel Martins, Rodolfo Pereira, Hélder Ribeiro, Fátima Neves, Pedro Mateus, Ilídio Moreira, Luís Vouga" "autores" => array:8 [ 0 => array:2 [ "nombre" => "Catarina" "apellidos" => "Ferreira" ] 1 => array:2 [ "nombre" => "Daniel" "apellidos" => "Martins" ] 2 => array:2 [ "nombre" => "Rodolfo" "apellidos" => "Pereira" ] 3 => array:2 [ "nombre" => "Hélder" "apellidos" => "Ribeiro" ] 4 => array:2 [ "nombre" => "Fátima" "apellidos" => "Neves" ] 5 => array:2 [ "nombre" => "Pedro" "apellidos" => "Mateus" ] 6 => array:2 [ "nombre" => "Ilídio" "apellidos" => "Moreira" ] 7 => array:2 [ "nombre" => "Luís" "apellidos" => "Vouga" ] ] ] ] ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113000814?idApp=UINPBA00004E" "url" => "/08702551/0000003200000009/v1_201309260109/S0870255113000814/v1_201309260109/pt/main.assets" ] "itemAnterior" => array:20 [ "pii" => "S0870255113000437" "issn" => "08702551" "doi" => "10.1016/j.repc.2012.12.011" "estado" => "S300" "fechaPublicacion" => "2013-09-01" "aid" => "259" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "sco" "cita" => "Rev Port Cardiol. 2013;32:701-6" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 11295 "formatos" => array:3 [ "EPUB" => 190 "HTML" => 9600 "PDF" => 1505 ] ] "pt" => array:13 [ "idiomaDefecto" => true "cabecera" => "Caso Clínico" "titulo" => "Estenose aórtica grave e choque cardiogénico: um desafio terapêutico" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "tieneResumen" => array:2 [ 0 => "pt" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "701" "paginaFinal" => "706" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Severe aortic stenosis and cardiogenic shock: A therapeutic challenge" ] ] "contieneResumen" => array:2 [ "pt" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 791 "Ancho" => 825 "Tamanyo" => 56871 ] ] "descripcion" => array:1 [ "pt" => "Valvuloplastia aórtica com balão NUCLEUS 20mm, sob ritmo de pacing a 220 bpm." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Francisca Caetano, Inês Almeida, Luís Seca, Ana Botelho, Paula Mota, António Leitão Marques" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Francisca" "apellidos" => "Caetano" ] 1 => array:2 [ "nombre" => "Inês" "apellidos" => "Almeida" ] 2 => array:2 [ "nombre" => "Luís" "apellidos" => "Seca" ] 3 => array:2 [ "nombre" => "Ana" "apellidos" => "Botelho" ] 4 => array:2 [ "nombre" => "Paula" "apellidos" => "Mota" ] 5 => array:2 [ "nombre" => "António" "apellidos" => "Leitão Marques" ] ] ] ] ] "idiomaDefecto" => "pt" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2174204913001761" "doi" => "10.1016/j.repce.2013.10.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913001761?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113000437?idApp=UINPBA00004E" "url" => "/08702551/0000003200000009/v1_201309260109/S0870255113000437/v1_201309260109/pt/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Case report" "titulo" => "Churg–Strauss syndrome presenting with eosinophilic myocarditis: A diagnostic challenge" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "707" "paginaFinal" => "711" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Ana Sofia Correia, Alexandra Gonçalves, Vítor Araújo, João Almeida e Silva, José Manuel Pereira, Pedro Rodrigues Pereira, Manuel Pizarro, João Carlos Silva, Maria Júlia Maciel" "autores" => array:9 [ 0 => array:4 [ "nombre" => "Ana Sofia" "apellidos" => "Correia" "email" => array:1 [ 0 => "sofiakorreia@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "¿" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Alexandra" "apellidos" => "Gonçalves" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Vítor" "apellidos" => "Araújo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "João" "apellidos" => "Almeida e Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "José Manuel" "apellidos" => "Pereira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 5 => array:3 [ "nombre" => "Pedro" "apellidos" => "Rodrigues Pereira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 6 => array:3 [ "nombre" => "Manuel" "apellidos" => "Pizarro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "e" "identificador" => "aff0025" ] ] ] 7 => array:3 [ "nombre" => "João Carlos" "apellidos" => "Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 8 => array:3 [ "nombre" => "Maria Júlia" "apellidos" => "Maciel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Cardiology Department, Centro Hospitalar de São João, Porto, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Cardiology Department, Instituto Português de Oncologia (IPO), Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Intensive Care Unit, Centro Hospitalar de São João, Porto, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Pathological Anatomy Department, Centro Hospitalar de São João, Porto, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Internal Medicine Department, Centro Hospitalar de São João, Porto, Portugal" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Síndrome de Churg Strauss complicada com miocardite eosinofílica: um desafio diagnóstico" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 872 "Ancho" => 1400 "Tamanyo" => 315536 ] ] "descripcion" => array:1 [ "en" => "Hematoxylin and eosin cardiac biopsy specimen at presentation showing eosinophilic infiltration (A). Myocardial biopsy, after glucocorticoid and immunosuppressive therapy, showing complete resolution of eosinophilic myocarditis (B)." ] ] ] "textoCompleto" => "IntroductionChurg–Strauss syndrome (CSS) is a rare primary systemic vasculitis characterized by peripheral eosinophilia in patients with an atopic condition, typically with a previous history of asthma or allergy.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> It affects both small and medium-sized blood vessels of nearly all organ systems. The pathophysiology of this syndrome can be divided into three stages: first, a prodromal stage characterized by asthma and allergic manifestations; second, eosinophilic infiltration into tissues, predominantly the lungs and myocardium; and finally, a systemic stage, associated with the development of necrotizing vasculitis.<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a> Although cardiac involvement is unusual and often not prominent on initial presentation, subclinical myocardial abnormalities are frequent and are found in more than 50% of post-mortem examinations.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> Symptomatic cardiomyopathy carries a poor prognosis, accounting for about 50% of deaths, and is thus the major cause of mortality in CSS.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> It can present with eosinophilic vasculitis, myocarditis, pericarditis, pericardial effusion, fibrosis, valvular heart disease, conduction disorders, intracavitary thrombi, and cardiomyopathy.<a class="elsevierStyleCrossRefs" href="#bib0020">4–6</a> Death is usually due to myocardial infarction, heart failure, malignant ventricular arrhythmias, and/or cardiac tamponade.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>We describe the case of a patient with newly diagnosed CCS presenting with pronounced eosinophilic myocarditis and extensive focal vasculopathy on coronary angiography consistent with vasculitis. After appropriate and timely pharmacologic therapeutic intervention the symptoms resolved completely, as did the coronary lesions and myocardial infiltrates.Case reportA 22-year-old woman with a history of allergic rhinitis, asthma and repeated upper respiratory tract infections in the previous two years developed progressive asthenia, dizziness and left leg paresthesias. One month after the beginning of these non-specific symptoms she was hospitalized because of pleuritic chest pain. She had had no recent flu-like symptoms, either of the upper respiratory or gastrointestinal tract, or other symptoms suggestive of a previous infectious disease. Physical examination was unremarkable; the electrocardiogram (ECG) revealed poor anteroseptal R-wave progression and diffuse T-wave inversion (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A). Laboratory tests showed eosinophilia (3.83×109/l), elevated erythrocyte sedimentation rate (43 mm/h) and elevated biochemical markers of myocardial injury (peak troponin I 155.6 ng/ml). Serologic and PCR tests were negative for cardiotropic viruses, Aspergillus, Toxoplasma, Chlamydia psittaci and Mycoplasma pneumonia. Specific study for parasites was also negative.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Transthoracic echocardiography revealed a small pericardial effusion with no other abnormalities. A diagnosis of myopericarditis was assumed and anti-inflammatory therapy with ibuprofen was initiated. However, the patient's recurrent chest pain persisted, associated with dynamic ECG abnormalities (transient ST-segment elevation in inferior leads) (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B) and new wall motion abnormalities on echocardiography (inferior wall hypokinesia). Given the unfavorable clinical evolution associated with a significant rise in plasma troponin I concentration and new ECG and echocardiographic abnormalities, despite anti-inflammatory therapy, cardiac catheterization was performed on the fourth day after admission. Coronary arteriography demonstrated irregularity of the larger arteries with long diffuse stenotic lesions in the left anterior descending and right coronary arteries (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A and B, arrowed), consistent with diffuse vasculitis. A myocardial biopsy showed eosinophilic myocarditis (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A) and a concomitant nasal biopsy revealed eosinophilic necrotizing granulomatous vasculitis. Immunologic study, including ANCA antibodies, was negative, while electromyography revealed left saphenous nerve mononeuropathy.<elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia>Churg–Strauss syndrome was then diagnosed as four out of six criteria were present in this patient: (1) asthma; (2) eosinophilia; (3) mononeuropathy; (4) extravascular eosinophils.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> Pulse intravenous (i.v.) corticosteroid treatment (methylprednisolone 1 g i.v. daily for three days) was started, just after the biopsy results, followed by oral glucocorticoid therapy (prednisone 1.5 mg/kg daily) associated with cyclophosphamide (0.6 g/m2 intravenously once a month). On day one of treatment, the patient's symptoms improved significantly and levels of blood eosinophils fell to 0.02×109/l. Echocardiography performed after 18 days of treatment showed resolution of the pericardial effusion as well as of the left ventricular wall motion abnormalities. Control coronary angiography one year after initiation of therapy showed complete regression of coronary stenotic lesions (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>C and D) and a myocardial biopsy confirmed resolution of eosinophilic myocarditis (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>B). The patient was stable and symptom-free at one year of follow-up under chronic therapy.DiscussionWe describe the case of a patient with newly diagnosed CSS presenting with extensive myocarditis, which is an unusual clinical manifestation of this disease. According to the American College of Rheumatology, the presence of four or more of the six possible criteria – (1) asthma; (2) eosinophilia (>10% of leukocytes by differential cell count); (3) mononeuropathy or polyneuropathy; (4) migratory or transient pulmonary infiltrates; (5) paranasal sinus abnormality; and (6) extravascular eosinophils – establishes the diagnosis with a sensitivity of 85% and a specificity of 99%.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> In our case, a diagnosis of CSS was established based on the patient's history of asthma, hypereosinophilia, mononeuropathy and extravascular eosinophils on myocardial and nasal biopsy.This case report highlights the possibility of cardiac involvement in patients with CSS and calls attention to this differential diagnosis in the evaluation of myocarditis. This diagnosis is mostly overlooked because major cardiac problems are rarely the presenting manifestations of vasculitis. Involvement of the heart has been described in the third stage of the disease, as observed in our patient. It is usually associated with vasculitic lesions in the myocardium and coronary vessels causing (peri)myocarditis, heart failure, cardiac tamponade, myocardial infarction, or pericardial effusion.<a class="elsevierStyleCrossRefs" href="#bib0040">8–11</a> Our patient presented with pronounced myocarditis but pericardial effusion and coronary vasculitis were also evident. The myocardial damage is caused by vasculitis leading to coronary arteritis and coronary occlusion, through the release by activated eosinophils of toxic mediators causing direct myocardial damage,<a class="elsevierStyleCrossRef" href="#bib0060">12</a> or by replacement of the myocardium with granulomas and scar tissue.<a class="elsevierStyleCrossRefs" href="#bib0065">13,14</a> Patients with cardiac involvement are mainly ANCA-negative, as in this case.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>In general, the prognosis of CSS is good, with an overall 10-year survival of 81-92%.<a class="elsevierStyleCrossRefs" href="#bib0055">11,16</a> However, cardiac involvement is one of the most important predictors of an adverse outcome, causing up to 50% of CSS-related mortality.<a class="elsevierStyleCrossRefs" href="#bib0050">10,16</a> In a study on 96 patients,<a class="elsevierStyleCrossRef" href="#bib0080">16</a> 78-month survival was 90% in the absence of symptomatic cardiac manifestations, compared to 30% in their presence. Of the patients with myocardial involvement, 39% died in the acute stage of the disease.<a class="elsevierStyleCrossRef" href="#bib0080">16</a> Early diagnosis of cardiac involvement and subsequent adjuvant therapy may prevent progression of cardiac disease and improve prognosis in these patients. Patients with acute multiorgan disease should receive intravenous glucocorticoid (eg. methylprednisolone 1 g daily for three days) followed by oral glucocorticoid therapy.<a class="elsevierStyleCrossRefs" href="#bib0010">2,17</a> Prednisone doses of 0.5-1.5 mg/kg per day are typically administered until disease remission is attained and then gradually tapered to the lowest dose required for control of symptoms and signs of active CSS. The higher dose is used for patients with more aggressive disease, including those with cardiac involvement. Clinical remission of isolated pericarditis, without other visceral involvement, can be obtained with corticosteroid therapy alone.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> However, in the case of myocardial involvement the addition of immunosuppressive therapy is recommended. In higher-risk patients, including those with myocardial injury, lower mortality was noted among those who were treated with cyclophosphamide compared to a separate group in which only some patients received cyclophosphamide (7% vs. 26% mortality, respectively).<a class="elsevierStyleCrossRef" href="#bib0090">18</a> Cyclophosphamide may be administered orally every day or intravenously once a month, but insufficient data are available on CSS to make a clear recommendation regarding this choice. There is also disagreement concerning the duration of immunosuppressive therapy. However, in a preliminary study of patients with CSS, those receiving six pulses of cyclophosphamide had more relapses than those receiving 12 pulses (94% vs. 41%).<a class="elsevierStyleCrossRef" href="#bib0095">19</a> Further data are needed to clarify whether the benefits of 12 pulses outweigh the additional risks, especially of bladder toxicity. Our case report clearly demonstrates the possibility of complete reversal of cardiac disease with appropriate steroid and immunosuppressive therapy, which is in agreement with previous studies.<a class="elsevierStyleCrossRefs" href="#bib0095">19–22</a> However, this vasculitis can be fulminant if not identified early and may on occasion present with cardiogenic shock with a malignant course requiring urgent transplantation, despite therapy.<a class="elsevierStyleCrossRefs" href="#bib0115">23,24</a> Reports of heart transplantation in this setting are rare and only limited information is available on feasibility, outcome or relapse after heart transplantation in patients with CSS. While one case reported a good long-term result,<a class="elsevierStyleCrossRef" href="#bib0115">23</a> recurrent disease after initially successful transplantation was observed in another patient.<a class="elsevierStyleCrossRef" href="#bib0125">25</a> Cardiac involvement in CSS thus requires immediate therapy, which may allow recovery of cardiac function and reduce the significant cardiac mortality associated with CSS, underlining the need for an aggressive invasive diagnostic approach in CSS patients with heart lesions.Recent research with multimodality assessment, including ECG analysis, echocardiography and cardiac magnetic resonance imaging, has also shown a high incidence of cardiac involvement (62–90%) in patients with full clinical remission, characterized not only by fibrosis, but also by an active inflammatory process.<a class="elsevierStyleCrossRefs" href="#bib0130">26,27</a> Since cardiac involvement is one of the most important predictors of an adverse outcome,<a class="elsevierStyleCrossRef" href="#bib0090">18</a> these findings could influence current recommendations for cardiac evaluation and therapeutic decisions in asymptomatic patients. An early diagnosis detecting silent inflammation could be valuable,<a class="elsevierStyleCrossRef" href="#bib0140">28</a> since appropriate therapy can prevent progression to harmful episodes of cardiac disease and so reduce the high mortality associated with these manifestations. Systematic cardiac evaluation in asymptomatic patients with detailed imaging still lacks validation of its clinical benefit but could be an important procedure in the future.ConclusionBecause of its multiple forms of presentation and multiorgan involvement, diagnosis of CSS can be difficult. As reported here, it may present with severe cardiac disease. Cardiac involvement is a poor prognostic factor, and is a leading cause of mortality in CSS. As shown by this case report, appropriate and aggressive glucocorticoid and cyclophosphamide therapy may lead to complete recovery from potentially fatal cardiac disease. Physicians should thus be alert to the possibility of CSS as a differential diagnosis in patients presenting with myocarditis, whenever the clinical setting is appropriate. Prompt diagnosis and therapy can change the poor prognosis associated with cardiac involvement in CSS.Ethical disclosuresProtection of human and animal subjectsThe authors declare that no experiments were performed on humans or animals for this study.Confidentiality of dataThe authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study.Right to privacy and informed consentThe authors declare that no patient data appear in this article.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres276679" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec258633" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres276680" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec258634" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0025" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0040" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-07-25" "fechaAceptado" => "2012-10-12" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec258633" "palabras" => array:4 [ 0 => "Churg–Strauss syndrome" 1 => "Coronary vasculitis" 2 => "Eosinophilic myocarditis" 3 => "Complete reversal of cardiac involvement" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec258634" "palabras" => array:4 [ 0 => "Síndrome de Churg–Strauss" 1 => "Vasculite coronária" 2 => "Miocardite eosinofílica" 3 => "Reversão completa do envolvimento cardíaco" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Churg–Strauss syndrome (CSS) is an unusual disease that presents as systemic vasculitis and peripheral eosinophilia in patients with an atopic constitution. Cardiac involvement is unusual and often not prominent on initial presentation, but is an important cause of morbidity and mortality in patients with CSS. We report the case of a young woman with severe acute myocarditis. Coronary arteriography demonstrated extensive focal vasculopathy, consistent with coronary vasculitis, and myocardial biopsy showed eosinophilic myocarditis. This presentation led to an initial diagnosis of CSS in this patient and appropriate therapy resulted in a spectacular remission of disease activity." ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "A Síndrome de Churg-Strauss é uma doença rara que se caracteriza por vasculite sistémica associada a eosinofilia periférica, tipicamente em doentes com constituição atópica. O envolvimento cardíaco é incomum e geralmente discreto na apresentação inicial mas constitui uma importante causa de morbilidade e mortalidade nestes doentes. Descrevemos o caso de uma mulher jovem admitida por miocardite aguda. A angiografia coronária mostrou lesões coronárias difusas sugestivas de vasculite coronária e a biópsia miocárdica mostrou a presença de miocardite eosinofílica. Esta apresentação clínica permitiu o diagnóstico inaugural de síndrome de Churg-Strauss nesta doente e a instituição de terapêutica adequada resultou na remissão completa da atividade da doença." ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 424 "Ancho" => 1797 "Tamanyo" => 228211 ] ] "descripcion" => array:1 [ "en" => "Electrocardiography at presentation with diffuse T-wave inversion (A) and after recurrent chest pain with transient ST-segment elevation in inferior leads (B)." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 992 "Ancho" => 1000 "Tamanyo" => 106721 ] ] "descripcion" => array:1 [ "en" => "Coronary angiography at presentation showing diffuse vessel wall irregularities in the left anterior descending artery (A) and right coronary artery (B). Coronary angiography after one year of immunosuppressive therapy showing resolution of vasculopathy in the anterior descending artery (C) and right coronary artery (D)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 872 "Ancho" => 1400 "Tamanyo" => 315536 ] ] "descripcion" => array:1 [ "en" => "Hematoxylin and eosin cardiac biopsy specimen at presentation showing eosinophilic infiltration (A). Myocardial biopsy, after glucocorticoid and immunosuppressive therapy, showing complete resolution of eosinophilic myocarditis (B)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Allergic granulomatosis. Allergic angiitis and periarteritis nodosa" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Churg" 1 => "L. Strauss" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Pathol" "fecha" => "1951" "volumen" => "27" "paginaInicial" => "277" "paginaFinal" => "301" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14819261" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Churg–Strauss syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C. Pagnoux" 1 => "P. Guilpain" 2 => "L. Guillevin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/BOR.0b013e3280119854" "Revista" => array:6 [ "tituloSerie" => "Curr Opin Rheumatol" "fecha" => "2007" "volumen" => "19" "paginaInicial" => "25" "paginaFinal" => "32" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17143092" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Churg–Strauss syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "I. Noth" 1 => "M.E. Strek" 2 => "A.R. Leff" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(03)12518-4" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2003" "volumen" => "361" "paginaInicial" => "587" "paginaFinal" => "594" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12598156" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac involvement in the Churg–Strauss syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "G. Pelà" 1 => "G. Tirabassi" 2 => "P. Pattoneri" 3 => "L. Pavone" 4 => "G. Garini" 5 => "G. Bruschi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjcard.2005.11.088" "Revista" => array:6 [ "tituloSerie" => "Am J Cardiol" "fecha" => "2006" "volumen" => "97" "paginaInicial" => "1519" "paginaFinal" => "1524" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16679097" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eosinophilic disorders affecting the myocardium and endocardium: a review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C.J. Spry" 1 => "M. Take" 2 => "P.C. Tai" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Heart Vessels" "fecha" => "1985" "numero" => "Suppl. 1" "paginaInicial" => "240" "paginaFinal" => "242" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac involvement of Churg–Strauss syndrome demonstrated by magnetic resonance imaging" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.P. Smedema" 1 => "P. van Paasen" 2 => "M.J.P.G. van Kroonenburgh" 3 => "G. Snoep" 4 => "H.J.G.M. Crijns" 5 => "J.W. Cohen Tervaert" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Clin Exp Rheumatol" "fecha" => "2004" "volumen" => "22" "numero" => "Suppl. 36" "paginaInicial" => "S75" "paginaFinal" => "S78" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15675140" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The American College of Rheumatology 1990 criteria for the classification of Churg–Strauss syndrome (allergic granulomatosis and angiitis)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A.T. Masi" 1 => "G.G. Hunder" 2 => "J.T. Lie" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arthritis Rheum" "fecha" => "1990" "volumen" => "33" "paginaInicial" => "1094" "paginaFinal" => "1100" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2202307" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0040" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Allergic granulomatosis and angiitis (Churg–Strauss syndrome): report and analysis of 30 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L.C. Chumbley" 1 => "E.G. Harrison Jr." 2 => "R.A. DeRemee" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Mayo Clin Proc" "fecha" => "1997" "volumen" => "52" "paginaInicial" => "477" "paginaFinal" => "484" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18640" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0045" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Churg–Strauss syndrome: retrospective study of 20 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "C. Haas" 1 => "C. Le Jeunne" 2 => "P. Choubrac" 3 => "H. Durand" 4 => "F.C. Hugues" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Bull Acad Natl Med" "fecha" => "2001" "volumen" => "185" "paginaInicial" => "1113" "paginaFinal" => "1130" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11717829" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systemic vasculitis with asthma and eosinophilia: a clinical approach to the Churg–Strauss syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.G. Lanham" 1 => "K.B. Elkon" 2 => "C.D. Pusey" 3 => "G.R. Hughes" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Medicine (Baltimore)" "fecha" => "1984" "volumen" => "63" "paginaInicial" => "65" "paginaFinal" => "81" ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Churg–Strauss syndrome: outcome and long-term follow-up of 32 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Solans" 1 => "J.A. Bosch" 2 => "C. Perez-Bocanegra" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rheumatology (Oxford)" "fecha" => "2001" "volumen" => "40" "paginaInicial" => "763" "paginaFinal" => "771" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0060" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Toxic effects of human eosinophil products on isolated rat heart cells in vitro" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P.C. Tai" 1 => "D.J. Hayes" 2 => "J.B. Clark" 3 => "C.J. Spry" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Biochem J" "fecha" => "1982" "volumen" => "204" "paginaInicial" => "75" "paginaFinal" => "80" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7115333" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0065" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Churg–Strauss syndrome revealed by granulomatous acute pericarditis: two case reports and a review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "C. Agard" 1 => "E. Rendu" 2 => "V. Leguern" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.semarthrit.2006.12.002" "Revista" => array:6 [ "tituloSerie" => "Semin Arthritis Rheum" "fecha" => "2007" "volumen" => "36" "paginaInicial" => "386" "paginaFinal" => "391" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17303217" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0070" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Churg–Strauss syndrome complicated by eosinophilic endomyocarditis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "G. Ramakrishna" 1 => "H.M. Connolly" 2 => "H.D. Tazelaar" 3 => "C.J. Mullany" 4 => "D.E. Midthun" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Mayo Clin Proc" "fecha" => "2000" "volumen" => "75" "paginaInicial" => "631" "paginaFinal" => "635" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10852425" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0075" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Antineutrophil cytoplasmic antibodies and the Churg–Strauss syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Sable-Fourtassou" 1 => "P. Cohen" 2 => "A. Mahr" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ann Intern Med" "fecha" => "2005" "volumen" => "143" "paginaInicial" => "632" "paginaFinal" => "638" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16263885" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0080" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Churg–Strauss syndrome: clinical study and long-term follow-up of 96 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L. Guillevin" 1 => "P. Cohen" 2 => "M. Gayraud" 3 => "F. Lhote" 4 => "B. Jarrousse" 5 => "P. Casassus" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Medicine (Baltimore)" "fecha" => "1999" "volumen" => "78" "paginaInicial" => "26" "paginaFinal" => "37" ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0085" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Churg–Strauss angiitis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R.A. Sinico" 1 => "P. Bottero" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.berh.2009.02.004" "Revista" => array:5 [ "tituloSerie" => "Best Pract Res Clin Rheumatol" "fecha" => "2009" "volumen" => "23" "paginaInicial" => "355" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19508943" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0090" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prognostic factors in polyarteritis nodosa and Churg–Strauss syndrome. A prospective study in 342 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "L. Guillevin" 1 => "F. Lhote" 2 => "M. Gayraud" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Medicine (Baltimore)" "fecha" => "1996" "volumen" => "75" "paginaInicial" => "17" "paginaFinal" => "28" ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0095" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Churg–Strauss syndrome with poor-prognosis factors: a prospective multicenter trial comparing glucocorticoids and six or twelve cyclophosphamide pulses in forty-eight patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "P. Cohen" 1 => "C. Pagnoux" 2 => "A. Mahr" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/art.22679" "Revista" => array:6 [ "tituloSerie" => "Arthritis Rheum" "fecha" => "2007" "volumen" => "57" "paginaInicial" => "686" "paginaFinal" => "693" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17471546" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0100" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac manifestations of Churg–Strauss syndrome: report of a case and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P.B. Hasley" 1 => "W.P. Follansbee" 2 => "J.L. Coulehan" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am Heart J" "fecha" => "1990" "volumen" => "120" "paginaInicial" => "996" "paginaFinal" => "999" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2220558" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0105" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prominent pericardial and myocardial lesions in the Churg–Strauss syndrome (allergic granulomatosis and angiitis)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A.G. Davison" 1 => "P.J. Thompson" 2 => "J. Davies" 3 => "B. Corrin" 4 => "M. Turner-Warwick" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "1983" "volumen" => "38" "paginaInicial" => "793" "paginaFinal" => "795" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6648860" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0110" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Necrotizing myocardial vasculitis in Churg–Strauss syndrome: clinicohistologic evaluation of steroids and immunosuppressive therapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Frustaci" 1 => "N. Gentiloni" 2 => "C. Chimenti" 3 => "L. Natale" 4 => "G. Gasbarrini" 5 => "A. Maseri" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1998" "volumen" => "114" "paginaInicial" => "1484" "paginaFinal" => "1489" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9824037" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0115" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Heart transplantation for Churg–Strauss syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "D. Thomson" 1 => "H. Chamsi-Pasha" 2 => "P. Hasleton" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Br Heart J" "fecha" => "1989" "volumen" => "62" "paginaInicial" => "409" "paginaFinal" => "410" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2590597" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0120" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Rapid progressive eosinophilic cardiomyopathy in a patient with Churg–Strauss syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Rosenberg" 1 => "H.M. Lorenz" 2 => "N. Gassler" 3 => "H.A. Katus" 4 => "N. Frey" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00392-006-0364-0" "Revista" => array:6 [ "tituloSerie" => "Clin Res Cardiol" "fecha" => "2006" "volumen" => "95" "paginaInicial" => "289" "paginaFinal" => "294" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16598400" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0125" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recurrence of Churg–Strauss vasculitis in a transplanted heart" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.A. Henderson" 1 => "P. Hasleton" 2 => "B.N. Hamid" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Br Heart J" "fecha" => "1993" "volumen" => "70" "paginaInicial" => "553" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8280522" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0130" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multimodality assessment of cardiac involvement in Churg–Strauss syndrome patients in clinical remission" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "W. Szczeklik" 1 => "T. Miszalski-Jamka" 2 => "L. Mastalerz" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Circ J" "fecha" => "2011" "volumen" => "75" "paginaInicial" => "649" "paginaFinal" => "655" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21139253" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0135" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiac involvement in Churg–Strauss syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R.M. Dennert" 1 => "P. van Paassen" 2 => "S. Schalla" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1002/art.27263" "Revista" => array:6 [ "tituloSerie" => "Arthritis Rheum" "fecha" => "2010" "volumen" => "62" "paginaInicial" => "627" "paginaFinal" => "634" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20112390" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0140" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiovascular magnetic resonance imaging detects cardiac involvement in Churg–Strauss syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Wassmuth" 1 => "U. Gobel" 2 => "A. Natusch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.cardfail.2008.07.227" "Revista" => array:6 [ "tituloSerie" => "J Card Fail" "fecha" => "2008" "volumen" => "14" "paginaInicial" => "856" "paginaFinal" => "860" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19041050" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000003200000009/v1_201309260109/S0870255113001224/v1_201309260109/en/main.assets" "Apartado" => array:4 [ "identificador" => "362" "tipo" => "SECCION" "pt" => array:2 [ "titulo" => "Casos clínicos" "idiomaDefecto" => true ] "idiomaDefecto" => "pt" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003200000009/v1_201309260109/S0870255113001224/v1_201309260109/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113001224?idApp=UINPBA00004E"]

Estatísticas

Case report

Síndrome de Churg Strauss complicada com miocardite eosinofílica: um desafio diagnóstico

Ana Sofia Correiaa,

Autor para correspondência

sofiakorreia@gmail.com

Corresponding author.

, Alexandra Gonçalvesa, Vítor Araújoa, João Almeida e Silvab, José Manuel Pereirac, Pedro Rodrigues Pereirad, Manuel Pizarroe, João Carlos Silvaa, Maria Júlia Maciela

a Cardiology Department, Centro Hospitalar de São João, Porto, Portugal

b Cardiology Department, Instituto Português de Oncologia (IPO), Porto, Portugal

c Intensive Care Unit, Centro Hospitalar de São João, Porto, Portugal

d Pathological Anatomy Department, Centro Hospitalar de São João, Porto, Portugal

e Internal Medicine Department, Centro Hospitalar de São João, Porto, Portugal

Lido

12817

Vezes
que se leu este artigo

2364

Total PDF

10453

Total HTML

Compartilhar estatísticas

 array:24 [
  "pii" => "S0870255113001224"
  "issn" => "08702551"
  "doi" => "10.1016/j.repc.2012.10.017"
  "estado" => "S300"
  "fechaPublicacion" => "2013-09-01"
  "aid" => "293"
  "copyright" => "Sociedade Portuguesa de Cardiologia"
  "copyrightAnyo" => "2012"
  "documento" => "article"
  "crossmark" => 0
  "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
  "subdocumento" => "sco"
  "cita" => "Rev Port Cardiol. 2013;32:707-11"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 8166
    "formatos" => array:3 [
      "EPUB" => 199
      "HTML" => 6855
      "PDF" => 1112
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S0870255113000814"
    "issn" => "08702551"
    "doi" => "10.1016/j.repc.2012.12.014"
    "estado" => "S300"
    "fechaPublicacion" => "2013-09-01"
    "aid" => "281"
    "copyright" => "Sociedade Portuguesa de Cardiologia"
    "documento" => "article"
    "crossmark" => 0
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "sco"
    "cita" => "Rev Port Cardiol. 2013;32:713-6"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 5742
      "formatos" => array:3 [
        "EPUB" => 193
        "HTML" => 4274
        "PDF" => 1275
      ]
    ]
    "pt" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Caso Cl&#237;nico</span>"
      "titulo" => "Les&#227;o tumoral gigante na aur&#237;cula esquerda&#58; um caso incomum de sarcoma card&#237;aco indiferenciado"
      "tienePdf" => "pt"
      "tieneTextoCompleto" => "pt"
      "tieneResumen" => array:2 [
        0 => "pt"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "713"
          "paginaFinal" => "716"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "en" => array:1 [
          "titulo" => "Giant tumoral lesion in the left atrium&#58; An uncommon case of undifferentiated cardiac sarcoma"
        ]
      ]
      "contieneResumen" => array:2 [
        "pt" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "pt" => true
      ]
      "contienePdf" => array:1 [
        "pt" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0020"
          "etiqueta" => "Figura 4"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr4.jpeg"
              "Alto" => 1050
              "Ancho" => 1583
              "Tamanyo" => 205280
            ]
          ]
          "descripcion" => array:1 [
            "pt" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Imagem da les&#227;o &#40;ap&#243;s ex&#233;rese cir&#250;rgica da mesma&#41;&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Catarina Ferreira, Daniel Martins, Rodolfo Pereira, H&#233;lder Ribeiro, F&#225;tima Neves, Pedro Mateus, Il&#237;dio Moreira, Lu&#237;s Vouga"
          "autores" => array:8 [
            0 => array:2 [
              "nombre" => "Catarina"
              "apellidos" => "Ferreira"
            ]
            1 => array:2 [
              "nombre" => "Daniel"
              "apellidos" => "Martins"
            ]
            2 => array:2 [
              "nombre" => "Rodolfo"
              "apellidos" => "Pereira"
            ]
            3 => array:2 [
              "nombre" => "H&#233;lder"
              "apellidos" => "Ribeiro"
            ]
            4 => array:2 [
              "nombre" => "F&#225;tima"
              "apellidos" => "Neves"
            ]
            5 => array:2 [
              "nombre" => "Pedro"
              "apellidos" => "Mateus"
            ]
            6 => array:2 [
              "nombre" => "Il&#237;dio"
              "apellidos" => "Moreira"
            ]
            7 => array:2 [
              "nombre" => "Lu&#237;s"
              "apellidos" => "Vouga"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "pt"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113000814?idApp=UINPBA00004E"
    "url" => "/08702551/0000003200000009/v1_201309260109/S0870255113000814/v1_201309260109/pt/main.assets"
  ]
  "itemAnterior" => array:20 [
    "pii" => "S0870255113000437"
    "issn" => "08702551"
    "doi" => "10.1016/j.repc.2012.12.011"
    "estado" => "S300"
    "fechaPublicacion" => "2013-09-01"
    "aid" => "259"
    "copyright" => "Sociedade Portuguesa de Cardiologia"
    "documento" => "article"
    "crossmark" => 0
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "sco"
    "cita" => "Rev Port Cardiol. 2013;32:701-6"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 11295
      "formatos" => array:3 [
        "EPUB" => 190
        "HTML" => 9600
        "PDF" => 1505
      ]
    ]
    "pt" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Caso Cl&#237;nico</span>"
      "titulo" => "Estenose a&#243;rtica grave e choque cardiog&#233;nico&#58; um desafio terap&#234;utico"
      "tienePdf" => "pt"
      "tieneTextoCompleto" => "pt"
      "tieneResumen" => array:2 [
        0 => "pt"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "701"
          "paginaFinal" => "706"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "en" => array:1 [
          "titulo" => "Severe aortic stenosis and cardiogenic shock&#58; A therapeutic challenge"
        ]
      ]
      "contieneResumen" => array:2 [
        "pt" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "pt" => true
      ]
      "contienePdf" => array:1 [
        "pt" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0015"
          "etiqueta" => "Figura 3"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr3.jpeg"
              "Alto" => 791
              "Ancho" => 825
              "Tamanyo" => 56871
            ]
          ]
          "descripcion" => array:1 [
            "pt" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Valvuloplastia a&#243;rtica com bal&#227;o NUCLEUS 20<span class="elsevierStyleHsp" style=""></span>mm&#44; sob ritmo de <span class="elsevierStyleItalic">pacing</span> a 220&#160;bpm&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Francisca Caetano, In&#234;s Almeida, Lu&#237;s Seca, Ana Botelho, Paula Mota, Ant&#243;nio Leit&#227;o Marques"
          "autores" => array:6 [
            0 => array:2 [
              "nombre" => "Francisca"
              "apellidos" => "Caetano"
            ]
            1 => array:2 [
              "nombre" => "In&#234;s"
              "apellidos" => "Almeida"
            ]
            2 => array:2 [
              "nombre" => "Lu&#237;s"
              "apellidos" => "Seca"
            ]
            3 => array:2 [
              "nombre" => "Ana"
              "apellidos" => "Botelho"
            ]
            4 => array:2 [
              "nombre" => "Paula"
              "apellidos" => "Mota"
            ]
            5 => array:2 [
              "nombre" => "Ant&#243;nio"
              "apellidos" => "Leit&#227;o Marques"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "pt"
    "Traduccion" => array:1 [
      "en" => array:9 [
        "pii" => "S2174204913001761"
        "doi" => "10.1016/j.repce.2013.10.012"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "en"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204913001761?idApp=UINPBA00004E"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113000437?idApp=UINPBA00004E"
    "url" => "/08702551/0000003200000009/v1_201309260109/S0870255113000437/v1_201309260109/pt/main.assets"
  ]
  "en" => array:19 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>"
    "titulo" => "Churg&#8211;Strauss syndrome presenting with eosinophilic myocarditis&#58; A diagnostic challenge"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "707"
        "paginaFinal" => "711"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Ana Sofia Correia, Alexandra Gon&#231;alves, V&#237;tor Ara&#250;jo, Jo&#227;o Almeida e Silva, Jos&#233; Manuel Pereira, Pedro Rodrigues Pereira, Manuel Pizarro, Jo&#227;o Carlos Silva, Maria J&#250;lia Maciel"
        "autores" => array:9 [
          0 => array:4 [
            "nombre" => "Ana Sofia"
            "apellidos" => "Correia"
            "email" => array:1 [
              0 => "sofiakorreia&#64;gmail&#46;com"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">¿</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Alexandra"
            "apellidos" => "Gon&#231;alves"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "V&#237;tor"
            "apellidos" => "Ara&#250;jo"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Jo&#227;o"
            "apellidos" => "Almeida e Silva"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "Jos&#233; Manuel"
            "apellidos" => "Pereira"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "Pedro"
            "apellidos" => "Rodrigues Pereira"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "aff0020"
              ]
            ]
          ]
          6 => array:3 [
            "nombre" => "Manuel"
            "apellidos" => "Pizarro"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">e</span>"
                "identificador" => "aff0025"
              ]
            ]
          ]
          7 => array:3 [
            "nombre" => "Jo&#227;o Carlos"
            "apellidos" => "Silva"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
          8 => array:3 [
            "nombre" => "Maria J&#250;lia"
            "apellidos" => "Maciel"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:5 [
          0 => array:3 [
            "entidad" => "Cardiology Department&#44; Centro Hospitalar de S&#227;o Jo&#227;o&#44; Porto&#44; Portugal"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "Cardiology Department&#44; Instituto Portugu&#234;s de Oncologia &#40;IPO&#41;&#44; Porto&#44; Portugal"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Intensive Care Unit&#44; Centro Hospitalar de S&#227;o Jo&#227;o&#44; Porto&#44; Portugal"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
          3 => array:3 [
            "entidad" => "Pathological Anatomy Department&#44; Centro Hospitalar de S&#227;o Jo&#227;o&#44; Porto&#44; Portugal"
            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "Internal Medicine Department&#44; Centro Hospitalar de S&#227;o Jo&#227;o&#44; Porto&#44; Portugal"
            "etiqueta" => "e"
            "identificador" => "aff0025"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "pt" => array:1 [
        "titulo" => "S&#237;ndrome de Churg Strauss complicada com miocardite eosinof&#237;lica&#58; um desafio diagn&#243;stico"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 872
            "Ancho" => 1400
            "Tamanyo" => 315536
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin and eosin cardiac biopsy specimen at presentation showing eosinophilic infiltration &#40;A&#41;&#46; Myocardial biopsy&#44; after glucocorticoid and immunosuppressive therapy&#44; showing complete resolution of eosinophilic myocarditis &#40;B&#41;&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Churg&#8211;Strauss syndrome &#40;CSS&#41; is a rare primary systemic vasculitis characterized by peripheral eosinophilia in patients with an atopic condition&#44; typically with a previous history of asthma or allergy&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It affects both small and medium-sized blood vessels of nearly all organ systems&#46; The pathophysiology of this syndrome can be divided into three stages&#58; first&#44; a prodromal stage characterized by asthma and allergic manifestations&#59; second&#44; eosinophilic infiltration into tissues&#44; predominantly the lungs and myocardium&#59; and finally&#44; a systemic stage&#44; associated with the development of necrotizing vasculitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Although cardiac involvement is unusual and often not prominent on initial presentation&#44; subclinical myocardial abnormalities are frequent and are found in more than 50&#37; of post-mortem examinations&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Symptomatic cardiomyopathy carries a poor prognosis&#44; accounting for about 50&#37; of deaths&#44; and is thus the major cause of mortality in CSS&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It can present with eosinophilic vasculitis&#44; myocarditis&#44; pericarditis&#44; pericardial effusion&#44; fibrosis&#44; valvular heart disease&#44; conduction disorders&#44; intracavitary thrombi&#44; and cardiomyopathy&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a> Death is usually due to myocardial infarction&#44; heart failure&#44; malignant ventricular arrhythmias&#44; and&#47;or cardiac tamponade&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of a patient with newly diagnosed CCS presenting with pronounced eosinophilic myocarditis and extensive focal vasculopathy on coronary angiography consistent with vasculitis&#46; After appropriate and timely pharmacologic therapeutic intervention the symptoms resolved completely&#44; as did the coronary lesions and myocardial infiltrates&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 22-year-old woman with a history of allergic rhinitis&#44; asthma and repeated upper respiratory tract infections in the previous two years developed progressive asthenia&#44; dizziness and left leg paresthesias&#46; One month after the beginning of these non-specific symptoms she was hospitalized because of pleuritic chest pain&#46; She had had no recent flu-like symptoms&#44; either of the upper respiratory or gastrointestinal tract&#44; or other symptoms suggestive of a previous infectious disease&#46; Physical examination was unremarkable&#59; the electrocardiogram &#40;ECG&#41; revealed poor anteroseptal R-wave progression and diffuse T-wave inversion &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A&#41;&#46; Laboratory tests showed eosinophilia &#40;3&#46;83<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;l&#41;&#44; elevated erythrocyte sedimentation rate &#40;43 mm&#47;h&#41; and elevated biochemical markers of myocardial injury &#40;peak troponin I 155&#46;6 ng&#47;ml&#41;&#46; Serologic and PCR tests were negative for cardiotropic viruses&#44; <span class="elsevierStyleItalic">Aspergillus</span>&#44; <span class="elsevierStyleItalic">Toxoplasma</span>&#44; <span class="elsevierStyleItalic">Chlamydia psittaci</span> and <span class="elsevierStyleItalic">Mycoplasma pneumonia</span>&#46; Specific study for parasites was also negative&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography revealed a small pericardial effusion with no other abnormalities&#46; A diagnosis of myopericarditis was assumed and anti-inflammatory therapy with ibuprofen was initiated&#46; However&#44; the patient&#39;s recurrent chest pain persisted&#44; associated with dynamic ECG abnormalities &#40;transient ST-segment elevation in inferior leads&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>B&#41; and new wall motion abnormalities on echocardiography &#40;inferior wall hypokinesia&#41;&#46; Given the unfavorable clinical evolution associated with a significant rise in plasma troponin I concentration and new ECG and echocardiographic abnormalities&#44; despite anti-inflammatory therapy&#44; cardiac catheterization was performed on the fourth day after admission&#46; Coronary arteriography demonstrated irregularity of the larger arteries with long diffuse stenotic lesions in the left anterior descending and right coronary arteries &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>A and B&#44; arrowed&#41;&#44; consistent with diffuse vasculitis&#46; A myocardial biopsy showed eosinophilic myocarditis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A&#41; and a concomitant nasal biopsy revealed eosinophilic necrotizing granulomatous vasculitis&#46; Immunologic study&#44; including ANCA antibodies&#44; was negative&#44; while electromyography revealed left saphenous nerve mononeuropathy&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Churg&#8211;Strauss syndrome was then diagnosed as four out of six criteria were present in this patient&#58; &#40;1&#41; asthma&#59; &#40;2&#41; eosinophilia&#59; &#40;3&#41; mononeuropathy&#59; &#40;4&#41; extravascular eosinophils&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Pulse intravenous &#40;i&#46;v&#46;&#41; corticosteroid treatment &#40;methylprednisolone 1 g i&#46;v&#46; daily for three days&#41; was started&#44; just after the biopsy results&#44; followed by oral glucocorticoid therapy &#40;prednisone 1&#46;5 mg&#47;kg daily&#41; associated with cyclophosphamide &#40;0&#46;6 g&#47;m<span class="elsevierStyleSup">2</span> intravenously once a month&#41;&#46; On day one of treatment&#44; the patient&#39;s symptoms improved significantly and levels of blood eosinophils fell to 0&#46;02<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleSup">9</span>&#47;l&#46; Echocardiography performed after 18 days of treatment showed resolution of the pericardial effusion as well as of the left ventricular wall motion abnormalities&#46; Control coronary angiography one year after initiation of therapy showed complete regression of coronary stenotic lesions &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>C and D&#41; and a myocardial biopsy confirmed resolution of eosinophilic myocarditis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>B&#41;&#46; The patient was stable and symptom-free at one year of follow-up under chronic therapy&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">We describe the case of a patient with newly diagnosed CSS presenting with extensive myocarditis&#44; which is an unusual clinical manifestation of this disease&#46; According to the American College of Rheumatology&#44; the presence of four or more of the six possible criteria &#8211; &#40;1&#41; asthma&#59; &#40;2&#41; eosinophilia &#40;&#62;10&#37; of leukocytes by differential cell count&#41;&#59; &#40;3&#41; mononeuropathy or polyneuropathy&#59; &#40;4&#41; migratory or transient pulmonary infiltrates&#59; &#40;5&#41; paranasal sinus abnormality&#59; and &#40;6&#41; extravascular eosinophils &#8211; establishes the diagnosis with a sensitivity of 85&#37; and a specificity of 99&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In our case&#44; a diagnosis of CSS was established based on the patient&#39;s history of asthma&#44; hypereosinophilia&#44; mononeuropathy and extravascular eosinophils on myocardial and nasal biopsy&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">This case report highlights the possibility of cardiac involvement in patients with CSS and calls attention to this differential diagnosis in the evaluation of myocarditis&#46; This diagnosis is mostly overlooked because major cardiac problems are rarely the presenting manifestations of vasculitis&#46; Involvement of the heart has been described in the third stage of the disease&#44; as observed in our patient&#46; It is usually associated with vasculitic lesions in the myocardium and coronary vessels causing &#40;peri&#41;myocarditis&#44; heart failure&#44; cardiac tamponade&#44; myocardial infarction&#44; or pericardial effusion&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#8211;11</span></a> Our patient presented with pronounced myocarditis but pericardial effusion and coronary vasculitis were also evident&#46; The myocardial damage is caused by vasculitis leading to coronary arteritis and coronary occlusion&#44; through the release by activated eosinophils of toxic mediators causing direct myocardial damage&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> or by replacement of the myocardium with granulomas and scar tissue&#46;<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13&#44;14</span></a> Patients with cardiac involvement are mainly ANCA-negative&#44; as in this case&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">In general&#44; the prognosis of CSS is good&#44; with an overall 10-year survival of 81-92&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;16</span></a> However&#44; cardiac involvement is one of the most important predictors of an adverse outcome&#44; causing up to 50&#37; of CSS-related mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;16</span></a> In a study on 96 patients&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> 78-month survival was 90&#37; in the absence of symptomatic cardiac manifestations&#44; compared to 30&#37; in their presence&#46; Of the patients with myocardial involvement&#44; 39&#37; died in the acute stage of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Early diagnosis of cardiac involvement and subsequent adjuvant therapy may prevent progression of cardiac disease and improve prognosis in these patients&#46; Patients with acute multiorgan disease should receive intravenous glucocorticoid &#40;eg&#46; methylprednisolone 1 g daily for three days&#41; followed by oral glucocorticoid therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;17</span></a> Prednisone doses of 0&#46;5-1&#46;5 mg&#47;kg per day are typically administered until disease remission is attained and then gradually tapered to the lowest dose required for control of symptoms and signs of active CSS&#46; The higher dose is used for patients with more aggressive disease&#44; including those with cardiac involvement&#46; Clinical remission of isolated pericarditis&#44; without other visceral involvement&#44; can be obtained with corticosteroid therapy alone&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> However&#44; in the case of myocardial involvement the addition of immunosuppressive therapy is recommended&#46; In higher-risk patients&#44; including those with myocardial injury&#44; lower mortality was noted among those who were treated with cyclophosphamide compared to a separate group in which only some patients received cyclophosphamide &#40;7&#37; vs&#46; 26&#37; mortality&#44; respectively&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Cyclophosphamide may be administered orally every day or intravenously once a month&#44; but insufficient data are available on CSS to make a clear recommendation regarding this choice&#46; There is also disagreement concerning the duration of immunosuppressive therapy&#46; However&#44; in a preliminary study of patients with CSS&#44; those receiving six pulses of cyclophosphamide had more relapses than those receiving 12 pulses &#40;94&#37; vs&#46; 41&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> Further data are needed to clarify whether the benefits of 12 pulses outweigh the additional risks&#44; especially of bladder toxicity&#46; Our case report clearly demonstrates the possibility of complete reversal of cardiac disease with appropriate steroid and immunosuppressive therapy&#44; which is in agreement with previous studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;22</span></a> However&#44; this vasculitis can be fulminant if not identified early and may on occasion present with cardiogenic shock with a malignant course requiring urgent transplantation&#44; despite therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">23&#44;24</span></a> Reports of heart transplantation in this setting are rare and only limited information is available on feasibility&#44; outcome or relapse after heart transplantation in patients with CSS&#46; While one case reported a good long-term result&#44;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> recurrent disease after initially successful transplantation was observed in another patient&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> Cardiac involvement in CSS thus requires immediate therapy&#44; which may allow recovery of cardiac function and reduce the significant cardiac mortality associated with CSS&#44; underlining the need for an aggressive invasive diagnostic approach in CSS patients with heart lesions&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Recent research with multimodality assessment&#44; including ECG analysis&#44; echocardiography and cardiac magnetic resonance imaging&#44; has also shown a high incidence of cardiac involvement &#40;62&#8211;90&#37;&#41; in patients with full clinical remission&#44; characterized not only by fibrosis&#44; but also by an active inflammatory process&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26&#44;27</span></a> Since cardiac involvement is one of the most important predictors of an adverse outcome&#44;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> these findings could influence current recommendations for cardiac evaluation and therapeutic decisions in asymptomatic patients&#46; An early diagnosis detecting silent inflammation could be valuable&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> since appropriate therapy can prevent progression to harmful episodes of cardiac disease and so reduce the high mortality associated with these manifestations&#46; Systematic cardiac evaluation in asymptomatic patients with detailed imaging still lacks validation of its clinical benefit but could be an important procedure in the future&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusion</span><p id="par0050" class="elsevierStylePara elsevierViewall">Because of its multiple forms of presentation and multiorgan involvement&#44; diagnosis of CSS can be difficult&#46; As reported here&#44; it may present with severe cardiac disease&#46; Cardiac involvement is a poor prognostic factor&#44; and is a leading cause of mortality in CSS&#46; As shown by this case report&#44; appropriate and aggressive glucocorticoid and cyclophosphamide therapy may lead to complete recovery from potentially fatal cardiac disease&#46; Physicians should thus be alert to the possibility of CSS as a differential diagnosis in patients presenting with myocarditis&#44; whenever the clinical setting is appropriate&#46; Prompt diagnosis and therapy can change the poor prognosis associated with cardiac involvement in CSS&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data and that all the patients included in the study received sufficient information and gave their written informed consent to participate in the study&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:11 [
        0 => array:2 [
          "identificador" => "xres276679"
          "titulo" => "Abstract"
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec258633"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres276680"
          "titulo" => "Resumo"
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec258634"
          "titulo" => "Palavras-chave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Case report"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discussion"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Conclusion"
        ]
        8 => array:3 [
          "identificador" => "sec0025"
          "titulo" => "Ethical disclosures"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Protection of human and animal subjects"
            ]
            1 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Confidentiality of data"
            ]
            2 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Right to privacy and informed consent"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conflicts of interest"
        ]
        10 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2012-07-25"
    "fechaAceptado" => "2012-10-12"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec258633"
          "palabras" => array:4 [
            0 => "Churg&#8211;Strauss syndrome"
            1 => "Coronary vasculitis"
            2 => "Eosinophilic myocarditis"
            3 => "Complete reversal of cardiac involvement"
          ]
        ]
      ]
      "pt" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec258634"
          "palabras" => array:4 [
            0 => "S&#237;ndrome de Churg&#8211;Strauss"
            1 => "Vasculite coron&#225;ria"
            2 => "Miocardite eosinof&#237;lica"
            3 => "Revers&#227;o completa do envolvimento card&#237;aco"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Churg&#8211;Strauss syndrome &#40;CSS&#41; is an unusual disease that presents as systemic vasculitis and peripheral eosinophilia in patients with an atopic constitution&#46; Cardiac involvement is unusual and often not prominent on initial presentation&#44; but is an important cause of morbidity and mortality in patients with CSS&#46; We report the case of a young woman with severe acute myocarditis&#46; Coronary arteriography demonstrated extensive focal vasculopathy&#44; consistent with coronary vasculitis&#44; and myocardial biopsy showed eosinophilic myocarditis&#46; This presentation led to an initial diagnosis of CSS in this patient and appropriate therapy resulted in a spectacular remission of disease activity&#46;</p>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A S&#237;ndrome de Churg-Strauss &#233; uma doen&#231;a rara que se caracteriza por vasculite sist&#233;mica associada a eosinofilia perif&#233;rica&#44; tipicamente em doentes com constitui&#231;&#227;o at&#243;pica&#46; O envolvimento card&#237;aco &#233; incomum e geralmente discreto na apresenta&#231;&#227;o inicial mas constitui uma importante causa de morbilidade e mortalidade nestes doentes&#46; Descrevemos o caso de uma mulher jovem admitida por miocardite aguda&#46; A angiografia coron&#225;ria mostrou les&#245;es coron&#225;rias difusas sugestivas de vasculite coron&#225;ria e a bi&#243;psia mioc&#225;rdica mostrou a presen&#231;a de miocardite eosinof&#237;lica&#46; Esta apresenta&#231;&#227;o cl&#237;nica permitiu o diagn&#243;stico inaugural de s&#237;ndrome de Churg-Strauss nesta doente e a institui&#231;&#227;o de terap&#234;utica adequada resultou na remiss&#227;o completa da atividade da doen&#231;a&#46;</p>"
      ]
    ]
    "multimedia" => array:3 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 424
            "Ancho" => 1797
            "Tamanyo" => 228211
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Electrocardiography at presentation with diffuse T-wave inversion &#40;A&#41; and after recurrent chest pain with transient ST-segment elevation in inferior leads &#40;B&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 992
            "Ancho" => 1000
            "Tamanyo" => 106721
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Coronary angiography at presentation showing diffuse vessel wall irregularities in the left anterior descending artery &#40;A&#41; and right coronary artery &#40;B&#41;&#46; Coronary angiography after one year of immunosuppressive therapy showing resolution of vasculopathy in the anterior descending artery &#40;C&#41; and right coronary artery &#40;D&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 872
            "Ancho" => 1400
            "Tamanyo" => 315536
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Hematoxylin and eosin cardiac biopsy specimen at presentation showing eosinophilic infiltration &#40;A&#41;&#46; Myocardial biopsy&#44; after glucocorticoid and immunosuppressive therapy&#44; showing complete resolution of eosinophilic myocarditis &#40;B&#41;&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:28 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Allergic granulomatosis&#46; Allergic angiitis and periarteritis nodosa"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "J&#46; Churg"
                            1 => "L&#46; Strauss"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Pathol"
                        "fecha" => "1951"
                        "volumen" => "27"
                        "paginaInicial" => "277"
                        "paginaFinal" => "301"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14819261"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Churg&#8211;Strauss syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "C&#46; Pagnoux"
                            1 => "P&#46; Guilpain"
                            2 => "L&#46; Guillevin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/BOR.0b013e3280119854"
                      "Revista" => array:6 [
                        "tituloSerie" => "Curr Opin Rheumatol"
                        "fecha" => "2007"
                        "volumen" => "19"
                        "paginaInicial" => "25"
                        "paginaFinal" => "32"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17143092"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Churg&#8211;Strauss syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "I&#46; Noth"
                            1 => "M&#46;E&#46; Strek"
                            2 => "A&#46;R&#46; Leff"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(03)12518-4"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2003"
                        "volumen" => "361"
                        "paginaInicial" => "587"
                        "paginaFinal" => "594"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12598156"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiac involvement in the Churg&#8211;Strauss syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "G&#46; Pel&#224;"
                            1 => "G&#46; Tirabassi"
                            2 => "P&#46; Pattoneri"
                            3 => "L&#46; Pavone"
                            4 => "G&#46; Garini"
                            5 => "G&#46; Bruschi"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.amjcard.2005.11.088"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Cardiol"
                        "fecha" => "2006"
                        "volumen" => "97"
                        "paginaInicial" => "1519"
                        "paginaFinal" => "1524"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16679097"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Eosinophilic disorders affecting the myocardium and endocardium&#58; a review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "C&#46;J&#46; Spry"
                            1 => "M&#46; Take"
                            2 => "P&#46;C&#46; Tai"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Heart Vessels"
                        "fecha" => "1985"
                        "numero" => "Suppl&#46; 1"
                        "paginaInicial" => "240"
                        "paginaFinal" => "242"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiac involvement of Churg&#8211;Strauss syndrome demonstrated by magnetic resonance imaging"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J&#46;P&#46; Smedema"
                            1 => "P&#46; van Paasen"
                            2 => "M&#46;J&#46;P&#46;G&#46; van Kroonenburgh"
                            3 => "G&#46; Snoep"
                            4 => "H&#46;J&#46;G&#46;M&#46; Crijns"
                            5 => "J&#46;W&#46; Cohen Tervaert"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Clin Exp Rheumatol"
                        "fecha" => "2004"
                        "volumen" => "22"
                        "numero" => "Suppl&#46; 36"
                        "paginaInicial" => "S75"
                        "paginaFinal" => "S78"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15675140"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The American College of Rheumatology 1990 criteria for the classification of Churg&#8211;Strauss syndrome &#40;allergic granulomatosis and angiitis&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46;T&#46; Masi"
                            1 => "G&#46;G&#46; Hunder"
                            2 => "J&#46;T&#46; Lie"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "1990"
                        "volumen" => "33"
                        "paginaInicial" => "1094"
                        "paginaFinal" => "1100"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2202307"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Allergic granulomatosis and angiitis &#40;Churg&#8211;Strauss syndrome&#41;&#58; report and analysis of 30 cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46;C&#46; Chumbley"
                            1 => "E&#46;G&#46; Harrison Jr&#46;"
                            2 => "R&#46;A&#46; DeRemee"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Mayo Clin Proc"
                        "fecha" => "1997"
                        "volumen" => "52"
                        "paginaInicial" => "477"
                        "paginaFinal" => "484"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18640"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Churg&#8211;Strauss syndrome&#58; retrospective study of 20 cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "C&#46; Haas"
                            1 => "C&#46; Le Jeunne"
                            2 => "P&#46; Choubrac"
                            3 => "H&#46; Durand"
                            4 => "F&#46;C&#46; Hugues"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Bull Acad Natl Med"
                        "fecha" => "2001"
                        "volumen" => "185"
                        "paginaInicial" => "1113"
                        "paginaFinal" => "1130"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11717829"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Systemic vasculitis with asthma and eosinophilia&#58; a clinical approach to the Churg&#8211;Strauss syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J&#46;G&#46; Lanham"
                            1 => "K&#46;B&#46; Elkon"
                            2 => "C&#46;D&#46; Pusey"
                            3 => "G&#46;R&#46; Hughes"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Medicine &#40;Baltimore&#41;"
                        "fecha" => "1984"
                        "volumen" => "63"
                        "paginaInicial" => "65"
                        "paginaFinal" => "81"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Churg&#8211;Strauss syndrome&#58; outcome and long-term follow-up of 32 patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46; Solans"
                            1 => "J&#46;A&#46; Bosch"
                            2 => "C&#46; Perez-Bocanegra"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rheumatology &#40;Oxford&#41;"
                        "fecha" => "2001"
                        "volumen" => "40"
                        "paginaInicial" => "763"
                        "paginaFinal" => "771"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Toxic effects of human eosinophil products on isolated rat heart cells in vitro"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "P&#46;C&#46; Tai"
                            1 => "D&#46;J&#46; Hayes"
                            2 => "J&#46;B&#46; Clark"
                            3 => "C&#46;J&#46; Spry"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Biochem J"
                        "fecha" => "1982"
                        "volumen" => "204"
                        "paginaInicial" => "75"
                        "paginaFinal" => "80"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7115333"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Churg&#8211;Strauss syndrome revealed by granulomatous acute pericarditis&#58; two case reports and a review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "C&#46; Agard"
                            1 => "E&#46; Rendu"
                            2 => "V&#46; Leguern"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.semarthrit.2006.12.002"
                      "Revista" => array:6 [
                        "tituloSerie" => "Semin Arthritis Rheum"
                        "fecha" => "2007"
                        "volumen" => "36"
                        "paginaInicial" => "386"
                        "paginaFinal" => "391"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17303217"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Churg&#8211;Strauss syndrome complicated by eosinophilic endomyocarditis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "G&#46; Ramakrishna"
                            1 => "H&#46;M&#46; Connolly"
                            2 => "H&#46;D&#46; Tazelaar"
                            3 => "C&#46;J&#46; Mullany"
                            4 => "D&#46;E&#46; Midthun"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Mayo Clin Proc"
                        "fecha" => "2000"
                        "volumen" => "75"
                        "paginaInicial" => "631"
                        "paginaFinal" => "635"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10852425"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antineutrophil cytoplasmic antibodies and the Churg&#8211;Strauss syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46; Sable-Fourtassou"
                            1 => "P&#46; Cohen"
                            2 => "A&#46; Mahr"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "2005"
                        "volumen" => "143"
                        "paginaInicial" => "632"
                        "paginaFinal" => "638"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16263885"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Churg&#8211;Strauss syndrome&#58; clinical study and long-term follow-up of 96 patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "L&#46; Guillevin"
                            1 => "P&#46; Cohen"
                            2 => "M&#46; Gayraud"
                            3 => "F&#46; Lhote"
                            4 => "B&#46; Jarrousse"
                            5 => "P&#46; Casassus"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Medicine &#40;Baltimore&#41;"
                        "fecha" => "1999"
                        "volumen" => "78"
                        "paginaInicial" => "26"
                        "paginaFinal" => "37"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Churg&#8211;Strauss angiitis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "R&#46;A&#46; Sinico"
                            1 => "P&#46; Bottero"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.berh.2009.02.004"
                      "Revista" => array:5 [
                        "tituloSerie" => "Best Pract Res Clin Rheumatol"
                        "fecha" => "2009"
                        "volumen" => "23"
                        "paginaInicial" => "355"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19508943"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prognostic factors in polyarteritis nodosa and Churg&#8211;Strauss syndrome&#46; A prospective study in 342 patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "L&#46; Guillevin"
                            1 => "F&#46; Lhote"
                            2 => "M&#46; Gayraud"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Medicine &#40;Baltimore&#41;"
                        "fecha" => "1996"
                        "volumen" => "75"
                        "paginaInicial" => "17"
                        "paginaFinal" => "28"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0095"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Churg&#8211;Strauss syndrome with poor-prognosis factors&#58; a prospective multicenter trial comparing glucocorticoids and six or twelve cyclophosphamide pulses in forty-eight patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "P&#46; Cohen"
                            1 => "C&#46; Pagnoux"
                            2 => "A&#46; Mahr"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/art.22679"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "2007"
                        "volumen" => "57"
                        "paginaInicial" => "686"
                        "paginaFinal" => "693"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17471546"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0100"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiac manifestations of Churg&#8211;Strauss syndrome&#58; report of a case and review of the literature"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "P&#46;B&#46; Hasley"
                            1 => "W&#46;P&#46; Follansbee"
                            2 => "J&#46;L&#46; Coulehan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am Heart J"
                        "fecha" => "1990"
                        "volumen" => "120"
                        "paginaInicial" => "996"
                        "paginaFinal" => "999"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2220558"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0105"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prominent pericardial and myocardial lesions in the Churg&#8211;Strauss syndrome &#40;allergic granulomatosis and angiitis&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46;G&#46; Davison"
                            1 => "P&#46;J&#46; Thompson"
                            2 => "J&#46; Davies"
                            3 => "B&#46; Corrin"
                            4 => "M&#46; Turner-Warwick"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "1983"
                        "volumen" => "38"
                        "paginaInicial" => "793"
                        "paginaFinal" => "795"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6648860"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0110"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Necrotizing myocardial vasculitis in Churg&#8211;Strauss syndrome&#58; clinicohistologic evaluation of steroids and immunosuppressive therapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46; Frustaci"
                            1 => "N&#46; Gentiloni"
                            2 => "C&#46; Chimenti"
                            3 => "L&#46; Natale"
                            4 => "G&#46; Gasbarrini"
                            5 => "A&#46; Maseri"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "1998"
                        "volumen" => "114"
                        "paginaInicial" => "1484"
                        "paginaFinal" => "1489"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9824037"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Heart transplantation for Churg&#8211;Strauss syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "D&#46; Thomson"
                            1 => "H&#46; Chamsi-Pasha"
                            2 => "P&#46; Hasleton"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Br Heart J"
                        "fecha" => "1989"
                        "volumen" => "62"
                        "paginaInicial" => "409"
                        "paginaFinal" => "410"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/2590597"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Rapid progressive eosinophilic cardiomyopathy in a patient with Churg&#8211;Strauss syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M&#46; Rosenberg"
                            1 => "H&#46;M&#46; Lorenz"
                            2 => "N&#46; Gassler"
                            3 => "H&#46;A&#46; Katus"
                            4 => "N&#46; Frey"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00392-006-0364-0"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Res Cardiol"
                        "fecha" => "2006"
                        "volumen" => "95"
                        "paginaInicial" => "289"
                        "paginaFinal" => "294"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16598400"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Recurrence of Churg&#8211;Strauss vasculitis in a transplanted heart"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "R&#46;A&#46; Henderson"
                            1 => "P&#46; Hasleton"
                            2 => "B&#46;N&#46; Hamid"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Br Heart J"
                        "fecha" => "1993"
                        "volumen" => "70"
                        "paginaInicial" => "553"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8280522"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Multimodality assessment of cardiac involvement in Churg&#8211;Strauss syndrome patients in clinical remission"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "W&#46; Szczeklik"
                            1 => "T&#46; Miszalski-Jamka"
                            2 => "L&#46; Mastalerz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Circ J"
                        "fecha" => "2011"
                        "volumen" => "75"
                        "paginaInicial" => "649"
                        "paginaFinal" => "655"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21139253"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiac involvement in Churg&#8211;Strauss syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46;M&#46; Dennert"
                            1 => "P&#46; van Paassen"
                            2 => "S&#46; Schalla"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1002/art.27263"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arthritis Rheum"
                        "fecha" => "2010"
                        "volumen" => "62"
                        "paginaInicial" => "627"
                        "paginaFinal" => "634"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20112390"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiovascular magnetic resonance imaging detects cardiac involvement in Churg&#8211;Strauss syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46; Wassmuth"
                            1 => "U&#46; Gobel"
                            2 => "A&#46; Natusch"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.cardfail.2008.07.227"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Card Fail"
                        "fecha" => "2008"
                        "volumen" => "14"
                        "paginaInicial" => "856"
                        "paginaFinal" => "860"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19041050"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/08702551/0000003200000009/v1_201309260109/S0870255113001224/v1_201309260109/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "362"
    "tipo" => "SECCION"
    "pt" => array:2 [
      "titulo" => "Casos cl&#237;nicos"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "pt"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/08702551/0000003200000009/v1_201309260109/S0870255113001224/v1_201309260109/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255113001224?idApp=UINPBA00004E"
]

Informação do artigo

ISSN: 08702551
Idioma original: Inglês

DOI:10.1016/j.repc.2012.10.017

Dados atualizados diariamente

Ano/Mês	Html	Pdf	Total

2024 Novembro	19	6	25
2024 Outubro	74	26	100
2024 Setembro	84	24	108
2024 Agosto	92	29	121
2024 Julho	56	33	89
2024 Junho	41	20	61
2024 Maio	56	16	72
2024 Abril	54	25	79
2024 Mar�o	56	25	81
2024 Fevereiro	42	20	62
2024 Janeiro	44	30	74
2023 Dezembro	48	19	67
2023 Novembro	46	27	73
2023 Outubro	36	19	55
2023 Setembro	54	32	86
2023 Agosto	37	16	53
2023 Julho	40	7	47
2023 Junho	56	11	67
2023 Maio	62	33	95
2023 Abril	52	8	60
2023 Mar�o	53	24	77
2023 Fevereiro	63	16	79
2023 Janeiro	46	12	58
2022 Dezembro	52	16	68
2022 Novembro	66	27	93
2022 Outubro	56	20	76
2022 Setembro	53	22	75
2022 Agosto	80	29	109
2022 Julho	59	36	95
2022 Junho	53	25	78
2022 Maio	44	30	74
2022 Abril	75	15	90
2022 Mar�o	83	35	118
2022 Fevereiro	90	20	110
2022 Janeiro	72	37	109
2021 Dezembro	52	34	86
2021 Novembro	56	38	94
2021 Outubro	89	39	128
2021 Setembro	73	31	104
2021 Agosto	63	35	98
2021 Julho	59	27	86
2021 Junho	70	23	93
2021 Maio	54	30	84
2021 Abril	124	75	199
2021 Mar�o	130	17	147
2021 Fevereiro	117	11	128
2021 Janeiro	70	13	83
2020 Dezembro	59	5	64
2020 Novembro	63	12	75
2020 Outubro	89	9	98
2020 Setembro	60	8	68
2020 Agosto	56	8	64
2020 Julho	50	6	56
2020 Junho	65	6	71
2020 Maio	56	2	58
2020 Abril	46	11	57
2020 Mar�o	76	13	89
2020 Fevereiro	132	29	161
2020 Janeiro	36	3	39
2019 Dezembro	73	8	81
2019 Novembro	34	2	36
2019 Outubro	27	7	34
2019 Setembro	82	7	89
2019 Agosto	39	9	48
2019 Julho	47	10	57
2019 Junho	62	6	68
2019 Maio	60	10	70
2019 Abril	36	15	51
2019 Mar�o	103	18	121
2019 Fevereiro	111	12	123
2019 Janeiro	127	5	132
2018 Dezembro	96	15	111
2018 Novembro	143	10	153
2018 Outubro	311	23	334
2018 Setembro	41	10	51
2018 Agosto	48	17	65
2018 Julho	39	10	49
2018 Junho	54	6	60
2018 Maio	77	8	85
2018 Abril	63	4	67
2018 Mar�o	98	8	106
2018 Fevereiro	72	3	75
2018 Janeiro	106	6	112
2017 Dezembro	144	13	157
2017 Novembro	70	11	81
2017 Outubro	49	11	60
2017 Setembro	53	11	64
2017 Agosto	73	14	87
2017 Julho	49	18	67
2017 Junho	48	10	58
2017 Maio	81	13	94
2017 Abril	49	4	53
2017 Mar�o	93	8	101
2017 Fevereiro	127	16	143
2017 Janeiro	46	11	57
2016 Dezembro	51	10	61
2016 Novembro	53	4	57
2016 Outubro	84	16	100
2016 Setembro	179	16	195
2016 Agosto	84	14	98
2016 Julho	34	13	47
2016 Junho	2	0	2
2016 Maio	27	14	41
2016 Abril	70	2	72
2016 Mar�o	127	23	150
2016 Fevereiro	126	33	159
2016 Janeiro	102	21	123
2015 Dezembro	146	25	171
2015 Novembro	127	16	143
2015 Outubro	121	25	146
2015 Setembro	128	18	146
2015 Agosto	119	20	139
2015 Julho	159	14	173
2015 Junho	107	5	112
2015 Maio	129	11	140
2015 Abril	101	18	119
2015 Mar�o	79	14	93
2015 Fevereiro	117	10	127
2015 Janeiro	141	10	151
2014 Dezembro	121	13	134
2014 Novembro	96	21	117
2014 Outubro	118	19	137
2014 Setembro	98	29	127
2014 Agosto	98	11	109
2014 Julho	118	15	133
2014 Junho	68	14	82
2014 Maio	79	17	96
2014 Abril	77	21	98
2014 Mar�o	101	17	118
2014 Fevereiro	106	23	129
2014 Janeiro	88	32	120
2013 Dezembro	87	20	107
2013 Novembro	112	49	161
2013 Outubro	93	59	152
2013 Setembro	10	8	18

Mostrar tudo

Indexada em:

Siga-nos:

Estatísticas

Indexada em:

Siga-nos:

Estatísticas

Receba a nossa Newsletter