title: Eosinophilic myocarditis in patients awaiting heart transplantation.
abstract: OBJECTIVE
  To determine the possible causative agents of eosinophilic or hypersensitivity myocarditis in patients awaiting heart transplantation.
  
  
  METHODS
  Consecutive patient series.
  
  
  METHODS
  Large university-affiliated hospital.
  
  
  METHODS
  A total of 190 consecutive patients who had heart transplantation at our center.
  
  
  METHODS
  The myocardium of the explanted heart was examined for a mixed inflammatory cell infiltrate containing an identifiable component of eosinophils. The relative quantity of each cell type was evaluated by a semiquantitative grading system (scored 0 to 3). The clinical findings and medications were reviewed, and patients were followed after heart transplantation.
  
  
  RESULTS
  Eosinophilic myocarditis (EM) was found in the explanted heart in 14 patients (7.4%). Myocardial infiltration by eosinophils ranged from mild (n = 6), often focal involvement to marked (n = 8), usually multifocal or widespread involvement. Twelve patients (86%) had peripheral blood eosinophilia before transplant, and in ten (71%), the eosinophil count at least doubled. Loop or thiazide diuretics were used in all 14 patients, and angiotensin-converting enzyme inhibitors were used in 12. Preoperative characteristics were similar in patients with and without EM, except for a higher frequency of inotropic support and assist devices in EM patients. Dobutamine was used in 12 (86%) and dopamine in seven (50%; one with dopamine alone), and one patient (7%) received neither dopamine nor dobutamine. In two patients receiving dobutamine and one receiving dopamine, tapering or discontinuation of the inotropic infusion resulted in a significant diminution of the peripheral eosinophilia and the EM before transplantation. Postoperative survival in patients with and without EM was similar at 8 yrs (50% +/- 13% and 54% +/- 4%, p =.34). No patient in this study has had EM on biopsy after transplant.
  
  
  CONCLUSIONS
  EM is a complication of multiple drug therapy in patients awaiting heart transplantation, and should be suspected when peripheral blood eosinophilia is present or the eosinophil count increases by at least two-fold. EM may be related to intravenous inotropic therapy, and this is the first study to document improvement in myocardial pathology after inotropic drug withdrawal. Hypersensitivity to thiazide and loop diuretics, angiotensin-converting enzyme inhibitors, and antibiotics must also be considered. Survival after heart transplantation is not impaired, and postoperative steroid therapy may prevent EM.
authors.affiliation: Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
authors.forename: Johanna J M
authors.initials: JJ
authors.lastname: Takkenberg
authors.forename: Lawrence S C
authors.initials: LS
authors.lastname: Czer
authors.forename: Michael C
authors.initials: MC
authors.lastname: Fishbein
authors.forename: Daniel J
authors.initials: DJ
authors.lastname: Luthringer
authors.forename: Adrian W
authors.initials: AW
authors.lastname: Quartel
authors.forename: James
authors.initials: J
authors.lastname: Mirocha
authors.forename: Carmen A
authors.initials: CA
authors.lastname: Queral
authors.forename: Carlos
authors.initials: C
authors.lastname: Blanche
authors.forename: Alfredo
authors.initials: A
authors.lastname: Trento
mesh_terms: D000806:Angiotensin-Converting Enzyme Inhibitors / Q000008:administration & dosage / Q000009:adverse effects; D002316:Cardiotonic Agents / Q000008:administration & dosage / Q000009:adverse effects*; D004232:Diuretics / Q000008:administration & dosage / Q000009:adverse effects; D004280:Dobutamine / Q000008:administration & dosage / Q000009:adverse effects*; D004298:Dopamine / Q000008:administration & dosage / Q000009:adverse effects; D004342:Drug Hypersensitivity / Q000453:epidemiology / Q000209:etiology* / Q000473:pathology; D004359:Drug Therapy, Combination; D004802:Eosinophilia / Q000139:chemically induced* / Q000453:epidemiology / Q000276:immunology / Q000473:pathology; D005260:Female; D016027:Heart Transplantation / Q000401:mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D009205:Myocarditis / Q000139:chemically induced* / Q000453:epidemiology / Q000276:immunology / Q000473:pathology; D018709:Statistics, Nonparametric; D015996:Survival Rate; D014481:United States / Q000453:epidemiology
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors; D002316:Cardiotonic Agents; D004232:Diuretics; D004280:Dobutamine; D004298:Dopamine