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.