A case of hypereosinophilic syndrome with eosinophilic myocarditis secondary to nabumetone

Andrew Vissing,Nicholas Ward

doi:10.5348/101151z01av2020cr

Abstract

Introduction: Hypereosinophilic syndromes are a group of disorders defined by an absolute eosinophil count greater than 1.5 × 109/L that leads to eosinophil-mediated end-organ damage. Cardiac involvement can range from asymptomatic inflammation of the myocardium to endomyocardial fibrosis and irreversible constrictive cardiomyopathy. Case Report: We present the case of a patient who presented with confusion and was found to have an absolute eosinophil count of 8.08 × 109/L as well as clinical findings consistent with eosinophilic myocarditis. It was determined that her clinical presentation was due to a new medication she had taken, nabumetone. Other causes of hypereosinophilia were ruled out. She improved with two days of pulse dose methylprednisolone and subsequent prednisone taper with complete resolution of her cardiomyopathy and normalization of her absolute eosinophil count. Conclusion: While there are no guidelines available for the treatment of eosinophilic myocarditis, corticosteroids should be considered in patients with evidence of cardiomyopathy in the setting of hypereosinophilia. Hypereosinophilic syndrome is an uncommonly recognized adverse event of non-steroidal anti-inflammatory drug (NSAID) therapy.

Highlights

Hypereosinophilic syndromes are a group of disorders defined by an absolute eosinophil count greater than 1.5 × 109/L that leads to eosinophil-mediated end-organ damage
Hypereosinophilic syndrome is a rare entity that requires prompt diagnosis and work-up to ensure proper therapy as it can lead to significant endorgan damage including venous thromboembolisms, pulmonary fibrosis, peripheral neuropathy, and encephalopathy
Non-steroidal anti-inflammatory drugs are an under-recognized cause of hypereosinophilic syndrome despite their widespread use in medicine

Summary

INTRODUCTION

Hypereosinophilic syndromes (HESs) are a rare group of disorders characterized by eosinophil overproduction leading to eosinophil-mediated multi-organ injury. Hypereosinophilic syndrome can result from neoplastic processes such as clonal myeloid disorders that lead to eosinophilic proliferation or can result as a reaction to another cause, for example, a parasitic infection or an adverse reaction from a medication [2]. The patient subsequently developed worsening encephalopathy a few hours after arrival to the general floor She underwent repeat head CT imaging, which revealed acute ischemic multi-territory infarcts consistent with embolic strokes. The patient was deemed too unstable to undergo cardiac magnetic resonance imaging (MRI) and anticoagulation for prevention of cardiac thrombus formation was deferred due to her recent stroke She underwent a bone marrow biopsy on day 4 and was subsequently started on pulse dose steroids [intravenous (IV) methylprednisolone 500 mg twice daily] due to concern for eosinophilic myocarditis. She has returned to her baseline mental status and remains on 10 mg prednisone daily

DISCUSSION

CONCLUSION