ABC | Volume 110, Nº6, June 2018

Case Report Dinis et al. Eosinophilic miocarditis Arq Bras Cardiol. 2018; 110(6):597-599 Figure 1 – Cardiac magnetic resonance with subepicardial foci of edema and late enhancement of the myocardium in the left ventricle. Figure 2 – Endomyocardial biopsy with presence of eosinophils. and diffuse foci of late enhancement reflecting myocardial necrosis and fibrosis. 4 The presence of pericardial effusion and left ventricular systolic dysfunction reinforce the evidence of myocarditis. In stable patients, it is reasonable to perform cardiac magnetic resonance imaging prior to biopsy, since the former may help to identify focal pathology through late enhancement. However, in unstable patients the biopsy should be a priority. 1 Endomyocardial biopsy is the only method that allows definitive diagnosis and identification of the underlying etiology. It has a sensitivity estimated at 50% due to sample errors. 1,2 Although it is the gold standard, in clinical practice it is not always performed, existing recommendations 1,8 for its execution, which are dependent on the clinic and the results of the complementary tests. The pseudo-ischemic presentation of the patient, with elevation of markers of myocardial necrosis and exclusion of epicardial coronary disease, and alterations in the imaging tests done, fulfilled the criteria for performing the biopsy. 1,8,9 In these cases, magnetic resonance imaging cardiac and endomyocardial biopsy together present synergies that go beyond the limitations that each exam presents separately. 9 The treatment and prognosis of eosinophilic myocarditis depends on its etiology. In the acute phase, restriction of physical activity is important. 1 In selected patients, particularly those with negative virology and suspected autoimmune etiology, early treatment with corticosteroids has shown favorable results. 5,10 Due to the clinical and hemodynamic stability of the patient, and after infective exclusion, we decided to postpone the onset of corticosteroids until confirmation of eosinophilic myocarditis. In the literature, it is described that a period of immunosuppressive therapy of six months can bring significant improvements in the left ventricular function (increase of 15-20% on the ejection 598