Congestive heart failure as presentation of acute lymphoblastic leukaemia with eosinophilia

Abstract

A previously healthy 17-year-old girl presented with the sudden onset of chest tightness accompanied by dyspnoea on exertion. Physical examination showed splinter haemorrhages and a grade III/VI systolic murmur at the left sternal border with no radiation. Laboratory data showed a white cell count of 49·8 × 109/l with 63% eosinophils (absolute eosinophil count of 31·4 × 109/l). The eosinophils showed no vacuolation or degranulation. Biochemical studies showed normal levels of creatine kinase and creatine kinase MB, but an elevated troponin-I of 2·19 (normal <0·034 ng/ml). Transthoracic echocardiography in the parasternal long-axis view disclosed an intracardiac thrombus (arrows), seen attached to the mitral valve at the left ventricular posterior wall, associated with mild mitral regurgitation (left panel: AO, aorta; LA, left atrium; LV, left ventricle, RV, right ventricle). The multidetector-row computed tomography image disclosed diffuse mural thrombus that occurred more in association with the posterior wall (arrows, right panel). A bone marrow biopsy demonstrated precursor B lymphoblastic leukaemia with 40% lymphoblasts and an increase of eosinophils and their precursors. Cytogenetic analysis of the bone marrow aspirate showed t(3;6)(p22;p24). Further studies relevant to a hypereosinophilic disorder disclosed normal levels of interleukin 5, no FIP1L1-PDGFRA fusion gene and negative stool examination for parasites and ova. The patient received chemotherapy according to a high-risk protocol for acute lymphoblastic leukaemia, which resulted in bone marrow remission and a return of the peripheral eosinophil count to normal by 8 weeks. Subsequent echocardiography showed resolution of the left ventricular endocardial thrombosis.