Chest Pain in a Middle-aged Woman With Asthma | Asthma | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

Chest Pain in a Middle-aged Woman With Asthma

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A woman in her 50s with discoid lupus in remission and recent adult-onset asthma presented to the emergency department with 2 weeks of dyspnea on exertion associated with substernal chest pain radiating to her jaw. She noted a 5-kg weight loss in the preceding 3 months. Examination revealed nonreproducible chest tenderness, bibasilar crackles, and no extra heart sounds. A 12-lead electrocardiogram is shown in Figure 1A. Testing revealed leukocytosis (white blood cell count, 16 900 cells/μL [to convert to × 109 cells/L, multiply by 0.001]) with a differential of 6% neutrophils and 59% eosinophils, an elevated N-terminal pro B-type natriuretic peptide of 3963 pg/mL (reference level, <900 pg/mL [to convert to ng/L, multiply by 1.0]), and an elevated initial troponin T of 0.36 ng/mL, which later peaked at 0.41 ng/mL (to convert to micrograms per liter, multiply by 1.0). Her C-reactive protein level was 3.09 mg/dL (normal, <0.5 mg/dL [to convert to milligrams per liter, multiply by 10]). Subsequent plasma flow cytometry demonstrated 65% eosinophils, and a bone marrow biopsy with immunohistochemistry showed eosinophilia without evidence of clonal expansion. Cardiac magnetic resonance imaging was performed (Figure 1B; Video).

Please finish quiz first before checking answer.

You answered correctly!

Read the answer below and download your certificate.

You answered incorrectly.

Read the discussion below and retake the quiz.

Eosinophilic myopericarditis associated with eosinophilic granulomatosis with polyangiitis

C. Urgent initiation of high-dose steroids, colchicine, and high-dose NSAIDs during hospitalization

The keys to the diagnosis in this case are the elevated biomarkers suggesting cardiac damage, decreased left ventricular ejection fraction, and late gadolinium enhancement on cardiac magnetic resonance imaging, all of which are consistent with myocardial injury. The patient’s peripheral eosinophilia without clonal expansion and history of adult-onset asthma are most suggestive of eosinophilic myopericarditis (EM) associated with eosinophilic granulomatosis with polyangiitis (EGPA), formerly known as Churg-Strauss syndrome.

Eosinophilic myopericarditis is a rare form of myocarditis characterized by eosinophilic infiltration of the myocardium.1 It can present with chest pain, acute heart failure, arrhythmias, and mural thrombus, and it is associated with high mortality, especially when presenting as fulminant myocarditis.2 This case highlights the broad differential diagnosis of EM causative mechanisms, which include primary neoplastic processes, helminthic and parasitic infections, allergic immune response and hypersensitivity, autoimmune diseases, and idiopathic hypereosinophilia.25 A recent meta-analysis found the most common causative mechanism of EM to be idiopathic or undefined (36%), followed by hypersensitivity (34%) and EGPA-associated (13%) causative mechanisms.2 Eosinophilic myopericarditis associated with EGPA is often accompanied by asthma and peripheral eosinophilia, as was the case with this patient.2

Survey Complete!

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Corresponding Author: David A. McNamara, MD, MPH, Frederik Meijer Heart & Vascular Institute, Spectrum Health, 2900 Bradford St NE, Grand Rapids, MI 49525 (david.mcnamara@spectrumhealth.org).

Published Online: August 12, 2020. doi:10.1001/jamacardio.2020.2808

Conflict of Interest Disclosures: Dr McNamara is supported by the National Heart, Lung, and Blood Institute (grant T32-HL125247). No other disclosures were reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Ginsberg  F , Parrillo  JE .  Eosinophilic myocarditis.   Heart Fail Clin. 2005;1(3):419-429. doi:10.1016/j.hfc.2005.06.013PubMedGoogle ScholarCrossref
2.
Brambatti  M , Matassini  MV , Adler  ED , Klingel  K , Camici  PG , Ammirati  E .  Eosinophilic myocarditis.   J Am Coll Cardiol. 2017;70(19):2363-2375. doi:10.1016/j.jacc.2017.09.023PubMedGoogle ScholarCrossref
3.
Kindermann  I , Barth  C , Mahfoud  F ,  et al.  Update on myocarditis.   J Am Coll Cardiol. 2012;59(9):779-792. doi:10.1016/j.jacc.2011.09.074PubMedGoogle ScholarCrossref
4.
Cooper  LT .  Myocarditis: From Bench to Bedside. Humana Press; 2003.
5.
Cheung  CC , Constantine  M , Ahmadi  A , Shiau  C , Chen  LYC .  Eosinophilic myocarditis.   Am J Med Sci. 2017;354(5):486-492. doi:10.1016/j.amjms.2017.04.002PubMedGoogle ScholarCrossref
6.
Morimoto  S , Kubo  N , Hiramitsu  S ,  et al.  Changes in the peripheral eosinophil count in patients with acute eosinophilic myocarditis.   Heart Vessels. 2003;18(4):193-196. doi:10.1007/s00380-003-0721-0PubMedGoogle ScholarCrossref
7.
Tefferi  A , Gotlib  J , Pardanani  A .  Hypereosinophilic syndrome and clonal eosinophilia.   Mayo Clin Proc. 2010;85(2):158-164. doi:10.4065/mcp.2009.0503PubMedGoogle ScholarCrossref
8.
Cooper  LT , Baughman  KL , Feldman  AM ,  et al; American Heart Association; American College of Cardiology; European Society of Cardiology; Heart Failure Society of America; Heart Failure Association of the European Society of Cardiology; Endorsed by the Heart Failure Society of America and the Heart Failure Association of the European Society of Cardiology.  The role of endomyocardial biopsy in the management of cardiovascular disease.   J Am Coll Cardiol. 2007;50(19):1914-1931. doi:10.1016/j.jacc.2007.09.008PubMedGoogle ScholarCrossref
9.
Wechsler  ME , Akuthota  P , Jayne  D ,  et al; EGPA Mepolizumab Study Team.  Mepolizumab or placebo for eosinophilic granulomatosis with polyangiitis.   N Engl J Med. 2017;376(20):1921-1932. doi:10.1056/NEJMoa1702079PubMedGoogle ScholarCrossref
10.
Song  T , Jones  DM , Homsi  Y .  Therapeutic effect of anti-IL-5 on eosinophilic myocarditis with large pericardial effusion.   BMJ Case Rep. 2017;2017:bcr-2016-218992. doi:10.1136/bcr-2016-218992PubMedGoogle Scholar
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close