Eosinophilic arteritis with coronary aneurysms and stenoses.

Journal of Invasive Cardiology 17(5):266-269 01 May 2005 Eosinophilic Arteritis with Coronary Aneurysms and Stenoses Paul B. Poommipanit, MD, Mark Lensky, MD, Jonathan Tobis, MD A 43-year-old Chinese woman with eosinophilia and a swollen neck was found to have extensive aneurysmal dilatation of both carotid arteries. Although there were no anginal symptoms, cardiac investigation revealed an abnormal radionuclide perfusion study. Cardiac catheterization showed large coronary aneurysms with complete occlusion of the left circumflex (LCx) and right coronary arteries (RCA), and 90% stenosis of the mid-left anterior descending (LAD) artery with an ejection fraction (EF) of 25%. Discussion of this unusual form of eosinophilic arteritis and its treatment are presented. Case Report. A 43-year-old Chinese woman, with a medical history of hypertension and severe patchy alopecia for two years, complained of painless “fullness of the neck” that developed six months prior to her hospitalization. A magnetic resonance imaging (MRI) study revealed aneurysmal carotid arteries with mural thrombi (Figure 1). The patient was started on anti-hypertensive medications as well as coumadin. A few days later, she developed sudden onset of right arm and leg weakness and was found to have a left parietal-occipital infarct by MRI. The patient’s white count was elevated at 11,000 with 65% eosinophilia. She was given high-dose steroids, and the eosinophilia resolved. The patient did not report any anginal symptoms, but because of the carotid involvement as well as symptoms of dyspnea on exertion and an elevated B-type naturetic peptide (BNP) of 1,140 pg/ml, an adenosine Myoview™ (Amersham Health, Waukesha, Wisconsin) study was performed. This showed large areas of ischemia and infarction in the anterior and inferolateral walls. Coronary angiography revealed diffuse aneurysmal dilatation of all three coronary arteries, associated with complete occlusion of the left circumflex artery (LCx), right coronary artery (RCA), and 90% stenosis of the mid-left anterior descending artery (LAD)(Figures 2A and B). The EF by ventriculography was 25% and demonstrated global hypokinesis. Right ventricle biopsy obtained two weeks after the institution of steroid therapy revealed no evidence of inflammatory infiltrate or eosinophilic myocarditis. A chromium cobalt 3.0 x 18 mm stent (Vision, Guidant Corp., Indianapolis, Indiana) was positioned across the LAD stenosis and was deployed at a pressure of 16 atm (Figure 3). Because the LAD represented the patient’s sole remaining coronary circulation, the procedure was performed with intra-aortic balloon pump (IABP) support. Neither the abdominal aorta nor the renal arteries were affected by the aneurysms. She was continued on high-dose corticosteroid therapy and subsequently received one dose of IV cyclophosphamide. After discharge from the hospital, she returned to her usual daily activities, with some residual weakness in the right arm and leg, but was clinically stable nine months later. Discussion 1. Vasculitis (Table 1). There are several vasculitides that affect large- and medium- sized arteries which share features with this case. Takayasu’s arteritis affects the aorta and its branches, which include the carotid and coronary arteries. 1 Our patient did not have involvement of the aorta or the subclavian branches. Takayasu’s arteritis is also not associated with eosinophilia. 2 Giant cell arteritis involves the large and medium vessels,