A RARE CASE OF EOSINOPHILIC MYOCARDITIS PRESENTING WITH REFRACTORY VENTRICULAR TACHYCARDIA AND CARDIOGENIC SHOCK

Background: Eosinophilic myocarditis (EM) is a rare etiology of cardiogenic shock. There are few reports of eosinophilic myositis associated with orbital myositis. Herein, we present a rare case of EM presented with refractory ventricular tachycardia (VT).Case: 55-Year-old female with medical history of orbital myositis on chronic oral prednisone, bicuspid aortic valve, abdominal aortic aneurysm. She presented to an outside hospital with palpitations and found to have a wide complex tachycardia with atrioventricular dissociation requiring subsequent cardioversions. Echocardiogram showed left ventricle ejection fraction at 51% and normal right ventricle. Coronary angiogram showed non-obstructive coronary artery disease. Course was complicated by refractory VT, intubation, and cardiogenic shock that warranted escalation of care. On arrival, patient was in VT storm and required multiple shocks despite anti-arrhythmics. Patient was placed on venoarterial extracorporeal membrane oxygenation(VA-ECMO).Decision-making: Due to rapid progression of her cardiogenic shock, giant cell myocarditis was suspected. Other differential included sarcoidosis, viral or other acute myocarditis. Due to instability, cardiac magnetic resonance was not performed. Endomyocardial biopsy revealed a small focus of eosinophils infiltrating a focus with myocardial cell damage and edema consistent with EM. There was no peripheral eosinophilia. Extensive rheumatological and autoimmune workup in addition to viral panels were negative. Patient was started on high dose steroids that was gradually tapered down to oral prednisone. Due persistent VT, VT ablation attempt was unsuccessful. Patient was deemed not a candidate for heart transplant. Eventually, with mexilitine, amiodarone and steroids, VA-ECMO was weaned off. Unfortunately, her course was also complicated by acute renal injury requiring hemodialysis, sepsis, and shock liver. Patient enrolled in hospice and expired.Conclusion: EM can be presented without peripheral eosinophilia. EM should be suspected in patients presenting with arrhythmia or cardiogenic shock and have history of orbital myositis for early immunosuppressive therapy.