Rapid Progression of Acute Necrotising Eosinophilic Myocarditis Secondary To T-Cell Lymphoma

Description of Clinical Presentation: A 47-year-old male with a history of peripheral T-cell lymphoma (diagnosed 3 years earlier) was admitted to hospital with diarrhoea and generalised malaise. During admission, he developed acute chest pain associated with hypotension and tachycardia. Investigations revealed a significantly elevated troponin T (2107g/L) and widespread ST-segment depression in leads V1–V6 on ECG. Concurrently, he developed acute thrombocytopenia (platelet count 42 10*9/L) with eosinophilia (8.4 10*9/L). A clinical diagnosis of myopericarditis was suspected.

Diagnostic Techniques and Their Most Important Findings: Cardiovascular magnetic resonance (CMR) demonstrated mild biventricular systolic impairment and diffuse symmetrical left ventricular thickening (maximal wall thickness 17 mm). Post-gadolinium contrast images revealed markedly abnormal nulling pattern and diffuse hyperenhancement on late-gadolinium enhancement (LGE) imaging. Extracellular volume (ECV) was significantly at 43% suggestive of infiltrative disease. T2 mapping values were normal except at the mid-inferior segment, where it was borderline elevated.



Four days later, a CT pulmonary angiogram was performed to exclude pulmonary embolism (PE) due to hypoxia and tachycardia. While no PE was identified, it showed lobar consolidation and an incidental mild-to-moderate pericardial effusion. Subsequent echocardiography confirmed a moderate, hemodynamically insignificant pericardial effusion and revealed new, marked echogenicity at the left ventricular (LV) apex, suggestive of combined left ventricular hypertrophy (LVH) and thrombus (Figure 1).



A repeat CMR 10 days after the initial study demonstrated obliteration of both ventricular apices with akinesia and large thrombus formation (Figure 2). Extensive LGE was observed, including circumferential subendocardial enhancement throughout both ventricles, generalised LGE of the entire lateral wall, and microvascular obstruction in the septum (Figure 3). ECV (49%) and T2 (70 ms) were both significantly elevated. Overall, these findings indicated hypereosinophilic syndrome (HES) with severe cardiac involvement

Learning Points from this Case: This case illustrates a rapidly progressive acute necrotising eosinophilic myocarditis secondary to T-cell lymphoma. It highlights the serial CMR features, evolving from initial eosinophilic infiltration to advanced stages of necrosis, extensive fibrosis, and thrombus formation. Eosinophilia is rare in T-cell lymphoma; when present alongside acute myocarditis, cardiac eosinophilic infiltration must be urgently excluded.

Figure 1; Four Chamber Echocardiography Image Showing Generalised LV Thickening With Marked Echogenicity At The LV Apex
Figure 2; Two Chamber Post Contrast Cine Image Demonstrating Obliteration Of The LV Apex With Thrombus Formation
Figure 3; Comparison Of Initial And Follow Up CMR Studies Illustrating Initial Infiltration Followed By Widespread Oedema and Thrombus Formation