Extract

A 54-year-old man presented with ischaemia of the distal lower extremities. He did not complain of chest pain or have electrocardiogram changes but did have a troponin leak. Transthoracic echocardiography (TTE) re-vealed bright echogenic laminar thrombus formation in the left (LV) (Panel A, arrows, Supplementary data online, Video S1) and right ventricular (RV) apices (Panel B, arrow). Contrast-enhanced imaging helped discern characteristics of the laminar thrombus (Panels B, E, arrows, Supplementary data online, Video S3). Thrombus extent could be appreciated on 3D TTE (Panel C). Complete blood count indicated chronically elevated absolute eosinophil count (1.1–2.6 k/mm3). Cardiac magnetic resonance imaging showed biventricular subendocardial late gadolinium enhancement with a large (3.4 × 1.6 cm) T1 hyperintense thrombus in the RV (Panel F, Supplementary data online, Video S4). The patient was anticoagulated with rivaroxaban fluorescence in situ hybridization positive for FIP1L1-PDGFRA confirmed the diagnosis of hyper-eosinophilic syndrome. Imatinib was never initiated.

Three-month follow-up TTE showed increased clot formation in the LV (Panels D, E, Supplementary data online, Video S2, S3), a thickened tricuspid valve with restricted motion, and severe regurgitation (Panels G, H, Supplementary data online, Video S5). One month later, the patient was readmitted owing to decline in neurological status. He underwent two episodes of pulseless electrical activity arrest with return of spontaneous circulation. Emergent TTE revealed the entire LV was obliterated with a large, dense eosinophilic clot (Panel I, Supplementary data online, Video S6). With poor prognosis, he was transitioned to comfort care measures and died that day.

You do not currently have access to this article.