Internal medicine resident University Of Toronto Toronto, Ontario, Canada
Background: Coronary vasospasms refractory to calcium channel blockers and nitrates may be secondary to a systemic process. Although rare, eosinophilic granulomatosis with polyangiitis (EGPA) can cause coronary vasospasms.
METHODS AND RESULTS: Case Summary: We report the case of a 33-year-old woman with a history of adult-onset asthma, hypothyroidism, and sinus polyposis who presented with recurrent chest pain and was found to have transient anteroseptal ST elevations with angiographic evidence of coronary vasospasm. Despite treatment with calcium channel blockers and nitrates, she experienced six recurrent anginal episodes and five cardiac arrests due to polymorphic ventricular tachycardia. Pre-arrest ECGs showed complete heart block and ST elevations. Eosinophilia progressed from 1.5 to 6.7 cells/L (50% of total WBC), with elevated IgE and positive RF. Cardiac MRI showed late gadolinium enhancement and myocardial edema. EGPA was suspected due to rising eosinophilia, history of asthma and polyposis, and MRI findings. She received IV pulse steroids followed by prednisone and cyclophosphamide for induction therapy. Her eosinophil count, CRP, and ESR normalized. ICD was implanted after stabilization. She remained symptom-free during 1.5 years of follow-up, receiving azathioprine for maintenance. Mepolizumab was added upon asthma relapse, allowing steroid tapering without symptom recurrence.
Conclusion: This case highlights that EGPA should be considered in patients with refractory coronary vasospasms and eosinophilia >10%, even in the absence of ANCA antibodies. Cardiac involvement in EGPA, though rare, can be life-threatening and mandates prompt recognition and aggressive immunosuppressive treatment. Early multidisciplinary involvement is critical for diagnosis and management . The most common cardiac manifestations are congestive heart failure, pericarditis, myocarditis, and arrhythmias.
