Low plasma level of all‐<i>trans</i> retinoic acid after feeding tube administration for acute promyelocytic leukemia
Authors: Kimitaka Takitani, Yoshitaka Nakao, Yoshiyuki Kosaka, Akiko Inoue, Chihiro Kawakami, Tomoko Kuno, Hiroshi Tamai
Journal: American Journal of Hematology (2004)

Eosinophilia Presenting as Acute Coronary SyndromeTo the Editor: Cardiovascular involvement in eosinophilia includes eosinophilic myocarditis, Lo¨ffler's endocarditis, and venous thromboembolism [1].Coronary vasculitis in major coronary artery with thrombus formation presenting as acute coronary syndrome was rarely reported. CASE REPORTA 27-year-old male was admitted with a 4-day history of exacerbating cough and dyspnea.He had had bronchial asthma for 2 years.Laboratory data showed a white blood cell count of 11.0 Â 10 9 /l, eosinophils 0.5 Â 10 9 /l, and C reactive protein 8.39 mg/dl.He was treated for acute asthma attack and bronchitis.However, his dyspnea deteriorated.CXR showed progressive enlargement of cardiac shadow and pulmonary edema.Coronary angiography revealed a total occlusion of the mid-left anterior descending coronary artery (LAD), and a large amount of thrombi in the left circumflex coronary artery.Antithrombin III, protein C, protein S, anti-nuclear antibody, and anti-cardiolipin antibody were normal.Percutaneous coronary intervention was unsuccessful.Ten days after admission, whole blood test showed eosinophilia (13.7 Â 10 9 /l).Endomyocardial biopsy disclosed eosinophilic endocarditis with mural thrombus (Fig. 1).Except for IgE of 4,497 IU/ml, the survey of the causes of eosinophilia was negative.There is no evidence of systemic vasculitis.Heart function deteriorated in spite of steroid therapy.He received orthotopic heart transplantation 6 months later.The pathology of the recipient's explanted heart revealed organized thrombus with recanalization within the original lumen of LAD.No evidence of atherosclerosis was found within coronary arteries.This case has two uncommon features.First, the initial eosinophil count only mildly elevated.We overlooked the diagnosis of eosinophilia until we rechecked the total eosinophil count again and performed the endomyocardial biopsy.Although the degree of organ damage usually correlates with the total eosinophil count [1], this case alerts us to re-examine the blood and the tissue involved when there is a clinical suspicion.The second uncommon feature is the presentation of acute coronary syndrome.Coronary involvement in eosinophilia usually limits to distal coronary arteries [2], as shown in patients with Churg-Strauss syndrome [3].Coronary vasculitis in major coronary artery with thrombus formation presenting as acute coronary syndrome, as in this case, was rarely reported in patients with eosinophilia.Eosinophils exert destructive effect on cardiomyocytes and endothelium by releasing eosinophil granule proteins, which in turn interfere with cell membrane permeability, mitochondria respiration, and intrinsic coagulation system [4].This case alerts us that, in patients with acute coronary syndrome, a past history of asthma, and a mildly elevated eosinophil count, eosinophilia with coronary thrombosis should be taken into account.