CASE PRESENTATION
A 65 year old man had been having fever, chills and a productive cough
with yellow sputum for four days prior to his presentation. He developed
right sided parasternal chest pain twenty-four hours before presenting
to the emergency department. The pain was worse on inspiration and he
was able to localize it with one finger. The past medical history was
significant for hyperlipidemia and coronary artery disease with ST
elevation myocardial infarction (STEMI) requiring stent placement in the
left anterior descending artery (LAD) 10 years prior to his admission.
On presentation, his blood pressure was 143/54, pulse rate 107,
respiratory rate was 18 and oxygen saturation was 98%. His temperature
was 102.7 F. He showed no signs of cardiopulmonary distress and clinical
examination of his cardiac, respiratory and abdominal systems showed no
abnormalities.
His initial investigations were significant for leukocytosis of 18.5k/uL
(neutrophil 57%, lymphocyte 6%, eosinophil 35%, monocyte 2%). His
cardiac troponin was elevated (5.77ng/ml). Electrocardiogram (EKG)
showed normal sinus rhythm and left bundle branch block which was
unchanged from prior EKGs. Chest X-ray reported right upper lobe
infiltrate concerning for pneumonia.
He was admitted for management of Non-ST Elevation Myocardial Infarction
(NSTEMI) in the setting of Pneumonia with high suspicion for
myopericarditis given his symptomatology. He was treated with aspirin,
clopidogrel, pravastatin, ceftriaxone and doxycycline and admitted to
cardiac telemetry unit.
His Echocardiogram (ECHO) showed left ventricular ejection fraction of
36-40% with moderate diastolic dysfunction which was not significantly
changed from a prior study one year ago. Left cardiac catheterization
showed non-obstructive coronary artery disease with patent LAD stent.
Over the ensuing days, he developed worsening peripheral eosinophilia of
72%. Peripheral smear showed normocytic normochromic anemia,
leukocytosis with eosinophils (no blasts) and normal platelets. Serum
Vitamin B12 was elevated (>1500pg/mL) and serum tryptase
was within normal limits (9ng/dl). He showed clinical improvement after
initiation of high dose steroids for the management of eosinophilic
myopericarditis. Bone marrow biopsy showed chronic myeloproliferative
neoplasm with eosinophilia with fusion of
FIP1L1 and PDGRA
genes. He was eventually discharged with outpatient hematology/oncology
follow-up and commenced treatment with Imatinib.