Thinking Outside the Heart

This Clinical Problem-Solving article details the diagnostic journey of a 50-year-old woman presenting with chest pain and dyspnea. Initially attributed to asthma and evaluated for cardiac and pulmonary causes including ACS, PE, and myopericarditis, her workup revealed elevated troponin, eosinophilia, and mediastinal lymphadenopathy. Cardiac MRI suggested pericardial inflammation with subtle myocardial edema. Negative coronary angiography excluded obstructive disease. Given systemic eosinophilia, allergic rhinitis, recent-onset asthma, and imaging findings, eosinophilic granulomatosis with polyangiitis (EGPA) was suspected. Endomyocardial biopsy confirmed eosinophilic vasculitis with granulomas. Treatment included intravenous glucocorticoids, cyclophosphamide, and IL-1 inhibition via anakinra, followed by azathioprine maintenance. The editorial contextualizes EGPA as an ANCA-associated vasculitis often presenting in phases atopic, eosinophilic, and vasculitic, with cardiac involvement common in ANCA-negative patients. Early recognition and biopsy-confirmed diagnosis are emphasized as essential for directing immunosuppressive therapy and preventing fatal outcomes.

This Clinical Problem-Solving article details the diagnostic journey of a 50-year-old woman presenting with chest pain and dyspnea. Initially attributed to asthma and evaluated for cardiac and pulmonary causes including ACS, PE, and myopericarditis, her workup revealed elevated troponin, eosinophilia, and mediastinal lymphadenopathy. Cardiac MRI suggested pericardial inflammation with subtle myocardial edema. Negative coronary angiography excluded obstructive disease. Given systemic eosinophilia, allergic rhinitis, recent-onset asthma, and imaging findings, eosinophilic granulomatosis with polyangiitis (EGPA) was suspected. Endomyocardial biopsy confirmed eosinophilic vasculitis with granulomas. Treatment included intravenous glucocorticoids, cyclophosphamide, and IL-1 inhibition via anakinra, followed by azathioprine maintenance. The editorial contextualizes EGPA as an ANCA-associated vasculitis often presenting in phases atopic, eosinophilic, and vasculitic, with cardiac involvement common in ANCA-negative patients. Early recognition and biopsy-confirmed diagnosis are emphasized as essential for directing immunosuppressive therapy and preventing fatal outcomes.