636 LOOKING AT THE BIGGER PICTURE: FROM ACUTE MYOCARDITIS TO THE DIAGNOSIS OF A MULTISYSTEMIC DISEASE

Abstract A 49-year-old man without cardiovascular risk factors, recently diagnosed of asthma and rino-sinusal polyposis, entered the Emergency Department for chest pain, shortness breath non-productive cough. The patient was in stable conditions. Laboratory exams showed eosinophilic leucocytosis (WBC 33.000/sqmm, 60% eosinophils) a mild elevation C-reactive protein (CRP 2,2 mg/dL). ECG sinus rhythm with flat T-waves antero-lateral leads. Troponin values were high but not suggestive acute myocardial damage (9900 - 9700 ng/L). Echocardiography normal biventricular volumes moderately depressed left ventricular ejection fraction (40%), hypokinesia wall mid-apical segments pericardial effusion. During hospital stay he developed progressive respiratory failure, transferred to tertiary center perform an endomyocardial biopsy (EMB) suspicion myocarditis. EMB multifocal interstitial sub-endocardial inflammatory infiltrates (predominantly foci myocellular damage, small vessels inflammation hypertrophy muscular tunica. overall picture consistent diffuse moderate myocarditis vasculitis. right heart cath performed same procedure during diuretic therapy hemodynamic profile (RAP 5 mmHg, PCWP 13 CI 3,7 L/min/sqm). treated dose steroids, first intravenously (methylprednisolone 125 mg/day three days), then orally (prednisone 80 mg/day) slow decalage until maintenance 12.5 mg daily. recent-onset hyper-eosinophilia rhino-sinus-bronchial syndrome light present cardiac condition granulomatosis polyangiitis (EGPA). Chest CT two areas ground glass at superior lobes. Other potential haematological infective causes hyper eosinophilia viral ruled out. After treatment, his clinical conditions improved, completely normalized, systolic function improved (LVEF 50%) eosinophil count significantly reduced (Eosinophils 830/sqmm, 8,9%), whereas resolution lung infiltrates. One month after discharge, still asymptomatic. Cardiac MRI 55%) circumferential subendocardial fibrosis involving only ventricle. complete vasculitic aspects. Eosinophil elevated (5660/sqmm, 36%). Therefore, steroidal raised 50 mg/day. rheumatologic evaluation, sparing strategy cyclophosphamide anti-IL5 antibody Mepolizumab adopted, good laboratory response. Three months later, no signs active disease. No further scheduled. Through presentation this unusual cause myocarditis, we want underscore importance early referral level patients suspected usefulness histology guide medical specific forms that can lead recovery.