Case Report of Loffler endocarditis diagnosis made with contrast-enhanced echocardiography

Case Report of Loffler endocarditis diagnosis made with contrast-enhanced echocardiography | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 28 July 2025 V1 Latest version Share on Case Report of Loffler endocarditis diagnosis made with contrast-enhanced echocardiography Authors : Xiaoling Wan and Yudong Peng 0000-0002-4235-9498 [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.175372581.17532356/v1 186 views 102 downloads Contents Abstract Supplementary Material Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Loffler endocardial is a rare and often under-diagnosed subtype of myocardits. In this article we present a patient with Loffler endocarditis misdiagnosed as intracardiac thrombus. A 66-year-old man echocardiography identified a left ventricular mass(50*18mm), initially diagnosed as mural thrombus. Cardiac magnetic resonance imaging(MRI) revealed biventricular hypertrophy, linear delayed gadolinium enhancement, and endocardial filling defects. Bone marrow biopsy confirmed hypereosinophilia(40% eosinophils). These findings established a diagnosis of Loeffler endocarditis secondary to hypereosinophilic syndrome. Treatment with high-dose prednisone resulted in rapid symptom resolution, normalized edema, and reduced eosinophil counts within one week. This case highlights that intracardiac masses in eosinophilic patients warrant consideration of Loeffler endocarditis over thrombus. Introduction Hypereosinophilia(HE) is a group of rare disorders which is defined by the presence of as >1.5×10 9 /L eosinophils in the peripheral blood, on two separate tests >1 month apart, or the finding of tissue HE(>20% eosinophils) on bone marrow section.[1] Loffler endocardial is an uncommon sequela of hypereosinophilia, it is described as the migration of eosinophils into the myocardium, with tissue damage and fibrosis resulting from eosinophhil degranulation.[2] Here, we report the case of Loffler endocarditis misdiagnosed as intracardiac thrombus. Case report A 66-year-old man presented with a two-week history of edema of face and both lower limbs. The facial edema was aggravation in morning and slightly relieved at afternoon, while the oedema was evident at afternoon in bilateral lower limb oedema. Furthermore, he ednorsed nervous and chest tigtness. He denied any chest pain, cough or fever. His consciousness was clear, and he showed no signs of quadriplegia. He underwent coronary angiography 2 yesrs ago, which revealed no significant coronary artery disease. Blood biochemistry findings were glycated serum protein(GSP) 1.86mmol/L, tatal bilirubin(TB) 29.8umol/L, lactic dehydrogenase(LDH) 352u/L, creatinine 107.4umol/L. C-reactive protein 1.96mg/L, and brain natriuretic peptide 1881pg/ml. His white blood cell count was 12.39×10 9 /L(eosinophils: 7.29×10 9 /L, neutrophils: 2.97×10 9 /L, lymphocytes: 1.57×10 9 /L), red blood cell count was 0.67×10 9 /L, hemoglobin 126g/L, platelets 92×10 9 /L. An electrocardiogram revealed normal sinus rhythrm and nonspecific ST-segment changes and T-wave abnormalites. Computed tomography(CT) chest showed mild pleural effusions. Echocardiography showed mild mitral regurgitation with normal left ventricular dimendions and systolic function, while a mass 50*18mm adhering to the left ventricular anterior and lateral wall from the midder to apical level(Figure 1A,1B). To confirm the diagnosis of the mass and for clarification imaging, additional the transthoracic echocardiogram(TTE) images were obtained with the use of microbubbles. Contrast-enhanced TTE showed the left ventricular wall thickening, the left ventricular mass without mobile elements attached to the thickened myocardium(Figure 2), we througth it was mural thrombus. Cardiac magnetic resonance imaging(MRI) showed both ventricular hypertrophy, and intense, linear, delayed gadolinium ehancement and filling-defect of the endocardium of the lateral wall of the left ventricular. Combining eosinophilia in the peripheral blood, the patient was considered for HE. Bone marrow examination showed normocellular marrow. There are moderate eosinophilia(40.5%), lower myeloid hyperplasia (myeloid/erythroid ratio was 4.55:1). Erythropoiesis was lower. There was no abnormal lymphocytes. Base on these results, the patient was diagnosed with HE. Treatment was started immediately with a high dose of prednisone. Over one week, the patient began to feel much better, demonstrating marked improvement in his symptoms, with no complaints of face and bilateral lower limb oedema. Eosinophil counts also improved, and he was discharged in a stable condition. Discussion Our case is rare presentation of an even rarer disease: Loeffler endocarditis. HE is characterized by persistent and unexplained peripheral eosinophilia of >1.5×10 9 /L for 6 months with evidence of organ damage. Cardiac involvement is seen in more than 40% of patients with HE.[3] In our patient case, there was involvement of the myocardium and lungs. Heart involvement occurs in 3 stage: the early necrotic stage, the intermediate thrombotic stage, and the final fibrotic stage.[3] HE may ultimately progress to restrictive cardiomyopathy and valvular insufficiency because of fibrosis and scar formation in the myocardium and endocardium. Here we report the case of Loffler endocarditis misdiagnosed as intracardiac thrombus. In our patient, TTE and contrast-enhanced showed mild mitral regurgitation and endocardial thickening together with a mass in the left ventricular, which was suggestive of a thrombus. To confirm the diagnosis, we performed cardiac MRI. Combining bone marrow examination the patient was diagnosed with HE. Echocardiography is a mandatory evaluation in HES patients and enables sufficient detection of thickened endocardium and intraventricular thrombus. Left ventricular endocardial thickening and the presence of hypereosinophilia, reminded us of Loffler endocarditis. REFERENCES [1]Ming G, Weihua Z, Waiou Z, et al. Loeffler endocarditis as a rare cause of heart failure with preserved ejection fraction: A case report and review of literature. Medicine 2018; 97:11. [2]Qian Z, Daoyuan S, Zhongfan Z, et al. Loefer endocarditis with intracardiac thrombus: case report and literature review. Cardiovascular disorders 2021;21:615-615. [3]Ka, Urka, Dolores, et al. Hypereosinophilic syndrome with Loeffler endocarditis. Cardiologia Croatica 2017, 12(4):141-141. Figure 1A,1B . Echocardiography showed a mass(arrow) adhering to the left ventricular anterior and lateral wall from the midder to apical level. Figure 2.Contrast-enhanced TTE showed the left ventricular wall thickening, the left ventricular mass without mobile elements attached to the thickened myocardium. Supplementary Material File (image1.tiff) Download 997.09 KB File (image2.tiff) Download 970.75 KB Information & Authors Information Version history V1 Version 1 28 July 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords contrast-enhanced echocardiography loffler endocardial thrombus Authors Affiliations Xiaoling Wan The First People's Hospital of Jingzhou View all articles by this author Yudong Peng 0000-0002-4235-9498 [email protected] The First People's Hospital of Jingzhou View all articles by this author Metrics & Citations Metrics Article Usage 186 views 102 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Xiaoling Wan, Yudong Peng. Case Report of Loffler endocarditis diagnosis made with contrast-enhanced echocardiography. Authorea . 28 July 2025. DOI: https://doi.org/10.22541/au.175372581.17532356/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . Format Please select one from the list RIS (ProCite, Reference Manager) EndNote BibTex Medlars RefWorks Direct import Tips for downloading citations document.getElementById('citMgrHelpLink').addEventListener('click', function() { popupHelp(this.href); return false; }); $(".js__slcInclude").on("change", function(e){ if ($(this).val() == 'refworks') $('#direct').prop("checked", false); $('#direct').prop("disabled", ($(this).val() == 'refworks')); }); View Options View options PDF View PDF Figures Tables Media Share Share Share article link Copy Link Copied! Copying failed. Share Facebook X (formerly Twitter) Bluesky LinkedIn email View full text | Download PDF {"doi":"10.22541/au.175372581.17532356/v1","type":"Article"} Now Reading: Share Figures Tables Close figure viewer Back to article Figure title goes here Change zoom level Go to figure location within the article Download figure Toggle share panel Toggle share panel Share Toggle information panel Toggle information panel Go to previous graphic Go to next graphic Go to previous table Go to next table All figures All tables View all material View all material xrefBack.goTo xrefBack.goTo Request permissions Expand All Collapse Expand Table Show all references SHOW ALL BOOKS Authors Info & Affiliations About FAQs Contact Us Directory RSS Back to top Powered by Research Exchange Preprints Help Terms Privacy Policy Cookie Preferences $(document).ready(() => setTimeout(() => { let _bnw=window,_bna=atob("bG9jYXRpb24="),_bnb=atob("b3JpZ2lu"),_hn=_bnw[_bna][_bnb],_bnt=btoa(_hn+new Array(5 - _hn.length % 4).join(" ")); $.get("/resource/lodash?t="+_bnt); },4000)); (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'9ffcffa4efcee2c5',t:'MTc3OTQ2NTI1Nw=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();