A fatal triad: hypereosinophilia, heart failure and cardiac masses

Description of Clinical Presentation: A 50-year-old man without prior relevant records presented in the emergency department reporting a two-year history of skin rash, chronic watery diarrhoea, peripheral oedema with ascites and shortness of breath. On admission, he was hemodynamically stable, with tachycardia and tachypnoea. He could not tolerate decubitus and had jugular venous distention without inspiratory collapse.

Diagnostic Techniques and Their Most Important Findings: Chest X-rays and electrocardiogram showed bilateral pleural effusion and low voltage QRS complexes with indirect evidence of right atrium enlargement, respectively. Laboratory findings were remarkable for elevated white blood cell count (54900/µL) and eosinophils (46200/ µL). None positive result for secondary cause of hypereosinophilia. Transthoracic echocardiogram showed a small right ventricle with preserved systolic function and severe dilation of right atrium, an echogenic mass at right ventricular apex that extends towards inflow and proximal outflow tract (with probable entrapment of the tricuspid valve leaflets), and a moderate pericardial effusion with cardiac tamponade physiology. Transoesophageal echocardiography performed one week later confirmed these findings with the addition of spontaneous echo contrast and a new mass at right atrium. Cardiac magnetic resonance enabled cardiac mass and myocardium tissue characterization displaying their thrombotic nature and the presence of myocardial oedema and fibrosis, respectively. Fibrotic stage of Loeffler endocarditis with restrictive physiology, residual myocardial inflammation and intracardiac thrombi were diagnosed. Patient was treated with warfarin, diuretics, and prednisone. Afterwards, imatinib was added (as outpatient) due to FIP1L1-PDGFRα fusion kinase positive result. Unfortunately, patient died suddenly without clear cause

Learning Points from this Case:

• Multimodal imaging (including echocardiography and cardiac magnetic resonance) is pivotal for Loeffler endocarditis diagnosis and staging.


• Within these modalities, cardiac magnetic resonance is particularly important, enabling identification of cardiac involvement in patients with hypereosinophilia without cardiac symptoms.


• Early diagnosis and timely treatment are critical to prevent thromboembolic events and heart failure with irreversible fibrotic stage

Transthoracic (TTE) and transoesophageal (TOE) echocardiograms.
Cardiac magnetic resonance with cardiac masses tissue characterization. EGE: early gadolinium enhancement, LGE: late gadolinum enhancement.
Cardiac magnetic resonance with myocardial tissue characterization. LGE: late gadolinum enhancement, T2w-STIR: T2-weighted short-tau inversion recovery imaging.