A Case of Lethal Peripartum Eosinophilic Myocarditis

The goal of this presentation is to report an uncommon case oflethal peripartum cardiomyopathy in a young woman. A completeforensic approach was performed through autopsy, histological, andmicrobiological examinations and final results showed that the cause ofdeath was due to an Eosinophilic Myocarditis (EM).This presentation will impact the forensic science communityshowing that eosinophilic myocarditis is a rare, potentially fatal diseaseif left untreated.Eosinophilic myocarditis is a histological diagnosis characterizedby a mixed inflammatory cell infiltrate containing a variable amount ofeosinophils within the myocardium. This phenomenon may beassociated with a variety of disease such as idiopathic hypereosinophilicsyndrome (IHES), hypersensitivity myocarditis, giant cell myocarditis,toxic myocarditis, Churg-Strauss syndrome, or parasitic infection.Clinical presentation includes a wide spectrum of nonspecific signsand symptoms: chest pain, fever, shortness of breath, chills, cough, butthey are not always present at the same time and sometimes unusualsymptoms, such as epigastric pain, can be the only indication of apathological state. They can be also associated with peripheraleosinophilia and transient or persistent left ventricular dysfunction.EM is considered, together with coronary heart dissection, one ofthe clinical presentations of peripartum cardiomyopathy that usuallyoccurs one month before to six months following delivery. EM etiologyand pathogenesis are unknown: eosinophils may be present andactivated because of the systemic hormonal perturbation occurringduring the period of uterine involution.A major problem is that EM is rarely recognized clinically and isoften first discovered only at postmortem examination.A correct diagnostic approach in these patients should include anechocardiogram study (with evidence of low ejection fraction anddecreased left ventricular systolic function) and an endomyocardialbiopsy (confirming eosinophils as a major inflammatory cellcomponent).If successfully diagnosed, EM can be treated with beta-blockers andACE inhibitors to support heart failure and corticosteroids to reduce theinflammatory process that is involving the myocardium. Prognosis isstrictly linked to ventricular function recovery because those patientswith severe myocarditis-induced heart failure have less survival chancesif normal cardiac function is not restored.Few EM cases are reported in literature and most of them are basedonly on autopsy diagnosis.A case is reported of a 29-year-old woman who was admitted tocritical care unit in respiratory and cardiac failure, three weeks aftergiving birth. Patient clinical history was non-existent for allergy orautoimmune diseases. The third day after birth, she complained ofthoracic pain but echocardiogram was negative. During hospitalizationphysicians treated her with antacids and gastric inhibitors and then shewas discharged with prescription of proton pump inhibitors with thesuggestion of gastroenterology visit. The following three weeks wherecharacterized by growing anterior and back thoracic pain associated withgeneral discomfort, but neither specific symptoms nor peripheraleosinophils increase were present; only inflammatory indexes (velocityof erythrocyte sedimentation, VES, and creatine kinase, CK) wereslightly increased. With progressive and worsening clinical symptoms,she was finally sent to emergency room in critical condition: dyspnea,confusion, fever, and tachycardia. Echocardiogram showed severe leftventricular systolic dysfunction and 25% of ejection fraction; chestradiograph and TC displayed pleural effusion with general edema. Theyoung woman died after seven hours of cardio-respiratory failure and nomedical approach was effective. External examination of the body wascompletely negative. Autopsy revealed bilateral pleural effusions,increased lung weights, and hep[...]