Pediatr Cardiol (2008) 29:983–985 DOI 10.1007/s00246-007-9135-6
CASE REPORT
Mitral Valve Destruction by Hodgkin’s Lymphoma-Associated Loefler Endocarditis Sergey Yalonetsky Æ David Mishaly Æ Ayelet Ben-Barak Æ Avraham Lorber
Received: 2 September 2007 / Accepted: 18 October 2007 / Published online: 15 November 2007 Ó Springer Science+Business Media, LLC 2007
Abstract We present a case of nearly total posterior mitral leaflet destruction due to Loeffler endocarditis associated with Hodgkin’s lymphoma in a 15-year-old adolescent. The patient was treated medically with subsequent surgical mitral valve replacement. Cardiac aspects of hypereosinophilic syndrome are also discussed. Keywords Loefler endocarditis Hodgkin’s lymphoma Mitral valve
Hypereosinophilic syndrome is a known complication of different hematological malignancies [4]. Loefler endocarditis is one of the clinical presentations of this syndrome. We present a rare case of Loefler endocarditis involving both mitral valve leaflets with nearly total destruction of the posterior leaflet. The cardiac manifestations were the initial presenting sings of Hodgkin’s lymphoma in this case.
S. Yalonetsky Pediatric Cardiology & GUCH, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel e-mail:
[email protected] D. Mishaly Cardiac Surgery, Shiva Medical Center, Tel Ha-Shomer, Israel A. Ben-Barak Pediatric Oncology & Haematology, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel A. Lorber (&) Pediatric Cardiology & GUCH, Rambam Health Care Campus, Technion Faculty of Medicine, Haifa, Israel e-mail:
[email protected]
Case Report A 15-year-old adolescent was referred to the emergency room due to acute respiratory distress. His past medical history was unremarkable. Physical examination revealed inspiratory rales over both lung fields and a 3/6 holosystolic heart murmur, maximal at the apical area. Chest X-ray revealed pulmonary edema and mediastinal widening. Laboratory studies were remarkable for hypereosinophilia: 70% eosinophils in the peripheral white blood count. The patient underwent computer tomography of the chest, which revealed a space- occupying lesion in the anterior mediastinum. Transthoracic echocardiography showed marked endocardial thickening and severe mitral regurgitation due to an almost complete destruction of the posterior mitral leaflet. Fine needle aspiration (FNA) from the anterior mediastinal tumor was diagnostic for Hodgkin’s lymphoma. It was concluded that the patient has a hypereosinophilic syndrome with Loefler endocarditis, which was an initial presentation of Hodgkin’s lymphoma. Intravenous chemotherapy was initiated with COPPABV (cyclophosphamide, vincristine, procarbazine, prednisone, doxorubicin, bleomycin, and vinblastine) protocol. After three courses, on evaluation done with positronemission tomography (PET-FDG) scan, the boy was in very good partial response. In addition to chemotherapy, the patient was treated by angiotensin-converting enzyme inhibitors and diuretics. After the initial control of the neoplastic disease, the patient underwent mitral valve replacement with a mechanical prosthesis (St Jude 29 mm). At surgery, a whitish mass was noted involving mitral valve leaflets, mitral annulus, and endocardial surface of the left ventricle below the mitral valve (Fig. 1). The mass was resected
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Fig. 1 Intraoperative view of the mitral valve. Redundant anterior leaflet, destructed posterior leaflet, and thickened subvalvular ventricular endocardium are seen
together with mitral leaflets. Mechanical prosthesis St Jude Medical 29 mm (St Jude Medical, Minneapolis, MN) was implanted. Pathology of the resected tissue reported no evidence of lymphoma and no microorganisms.
Discussion Hypereosinophilic syndrome is a rare systemic disease that might be idiopatic or appear in association with a malignant disease [4]. Loeffler endocarditis, eosynophilic endomyocardial disease, or fibroblastic endocarditis appears to be a subcategory of the hypereosinophilic syndrome with a predominant cardiac involvement [2]. Previous publications described valvular pathology in patients with idiopatic hypereosinophilic syndrome [5, 11], but the experience of Loeffler endocarditis associated with hemathologic malignancy is limited. Hodgkin’s lymphoma might be associated with hypereosinofilic syndrome [3, 10]. Eosinophilic meningitis [9] and eosinophilic folliculitis [12] were described in patients with Hodgkin’s lymphoma. One case report described Loeffler-type fibroblastic parietal endocarditis in a patient with Hodgkin’s lymphoma and eosinophilic leukemia [8]. To the best of our knowledge, our report is the first description of a patient with Loeffler endocarditis with severe destruction of the mitral valve in association with Hodgkin’s lymphoma. Congestive heart failure due to severe mitral incompetence was the presenting symptom of
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Hodgkin’s disease of this patient. The patient received chemotherapy and a remission was achieved. Mitral valve replacement was subsequently performed. Intraoperative macroscopic findings were compatible with Loeffler endocarditis, but microscopic evaluation of the resected tissue did not reveal eosinophilic infiltration following an effective chemotherapy [1, 6]. Previous studies described thrombotic complications in patients with hypereosinophilic syndrome and prosthetic mechanical valves due to exaggerated platelets aggregation [7, 13]. This led some researchers to recommend bioprostetic valve implantation in patients with Loeffler endocarditis to avoid such complication [5]. Our patient underwent mechanical mitral prosthesis implantation. Postoperative follow-up revealed a normal artificial valve function. It is assumed that thrombotic complications were prevented due to chemotherapyinduced remission.
Conclusion A patient with Loeffler endocarditis associated with Hodkin’s lymphoma and a complete destruction of the posterior mitral leaflet is presented. Congestive heart failure due to mitral regurgitation was the initial presentation of Hodgkin’s disease. Chemotherapy combined with medication to control heart failure followed by successful surgical valve replacement appeared to be an effective approach for this patient.
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