Clinical Commander

All dossiers
cardio.cardiogenic-shock.eosinophilic-myocarditis.v1

Cardiogenic shock — Eosinophilic myocarditis (hypersensitivity / parasitic / HES / EGPA)

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.cardiogenic-shock.core.v1 — narrowed to eosinophilic infiltration of myocardium causing acute LV dysfunction and shock per ESC 2013 myocarditis (Caforio PMID 23824828) + AHA 2020 myocarditis statement + Brambatti JACC 2017 case series. Distinct from giant-cell, lymphocytic (viral), and COVID phenotypes by eosinophil-rich infiltrate, frequent peripheral eosinophilia (>1500/µL), and pivotal STEROID RESPONSIVENESS. Etiology spectrum: (1) HYPERSENSITIVITY (drug-induced — antibiotics, antipsychotics, anticonvulsants, allopurinol; often DRESS syndrome); (2) PARASITIC (toxocara, schistosoma, trichinella, strongyloides — must exclude before steroids per CDC); (3) HYPEREOSINOPHILIC SYNDROME (HES — primary clonal FIP1L1-PDGFRA+ treated with imatinib per Cools NEJM 2003; secondary reactive); (4) EGPA (formerly Churg-Strauss — asthma + sinusitis + ANCA; steroids + cyclophosphamide/rituximab; mepolizumab approved); (5) IDIOPATHIC. Diagnosis: peripheral eosinophilia >1500/µL is the anchor; cardiac MRI with Lake Louise criteria + LGE (often subendocardial pattern); endomyocardial biopsy is GOLD STANDARD (eosinophilic infiltrate + necrosis + endomyocardial fibrosis); workup must exclude parasites + drug etiology + HES (FIP1L1-PDGFRA testing) + EGPA (ANCA, asthma history). Treatment: corticosteroids as foundation (methylprednisolone 1 g IV pulse × 3–5 d → prednisone 1 mg/kg/d taper over 6–12 mo) AFTER strongyloides exclusion; etiology-specific add-ons (imatinib for FIP1L1-PDGFRA+ HES; mepolizumab anti-IL-5 for steroid-refractory HES/EGPA; cyclophosphamide/rituximab for EGPA; antiparasitic for parasitic; drug withdrawal for hypersensitivity). Standard CS support per parent (cautious NE + MCS/Impella/VA-ECMO bridge). Mural thrombus prophylaxis (warfarin or apixaban × 3 mo) if EF<35 + endocardial involvement (Loeffler pattern). Outcomes: mortality 20–40% in shock presentation; rapid steroid response (24–72 h) is positive prognostic indicator; can fully recover or progress to restrictive cardiomyopathy + ICD eligibility for refractory ventricular arrhythmias from conduction system infiltration. Recurrence ~25% with rapid steroid taper. Inherits parent CS framework (vasopressor / inotrope ladder, MCS escalation, MDT activation); specialises for eosinophilic-specific disease-modifying therapy (steroid foundation), etiology-driven workup (parasite/drug/HES/EGPA), and multidisciplinary long-term care (cards, ID, rheum, heme, allergy/derm). Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-15 by shard-06-cardio-acute as Phase E wave 15 etiology variant.

Entry points (5)

  • lab_abnormality
    Peripheral absolute eosinophil count >1500/µL (often >5000) + new severe LV dysfunction + shock physiology — eosinophilic myocarditis until proven otherwise
    peripheral_eosinophilia_with_lv_dysfunction
  • history
    DRESS syndrome (fever + rash + lymphadenopathy + eosinophilia + multi-organ involvement) + new cardiac dysfunction → drug-induced hypersensitivity eosinophilic myocarditis
    dress_syndrome_with_cardiac_involvement
  • imaging
    Cardiac MRI: Lake Louise criteria positive (edema on T2 + early gadolinium enhancement + LGE) with subendocardial/endocardial-predominant LGE pattern + eosinophilia → eosinophilic myocarditis
    cmr_lake_louise_with_lge_endocardial_pattern
  • imaging
    Bedside echo: wall thickening + LV dysfunction + apical mural thrombus (endocardial eosinophil-mediated damage promotes thrombus) + peripheral eosinophilia
    echo_wall_thickening_lv_dysfunction_with_thrombus
  • history
    Asthma + sinusitis + ANCA-positive + new cardiac dysfunction → eosinophilic granulomatosis with polyangiitis (EGPA, formerly Churg-Strauss) cardiac involvement
    asthma_sinusitis_anca_with_cardiac_involvement

Required inputs (15)

  • agerequired
    demographic • used at CONTEXT
    Age affects steroid risk profile + comorbidity burden; HES presents in middle age (30–50); DRESS can occur at any age; EGPA peaks 40–60
  • sbprequired
    vital • used at RED_FLAGS
    SCAI 2022 staging baseline; eosinophilic myocarditis CS often responds rapidly to steroids
  • cbc_with_differentialrequired
    lab • used at INITIAL_WORKUP
    Absolute eosinophil count >1500/µL is the diagnostic anchor; >5000 strongly suggests HES; trend monitors steroid response
  • lactaterequired
    lab • used at RISK_STRATIFICATION
    SCAI 2022 staging + response to therapy; steroid response often shows rapid lactate clearance (within 24–48 h)
  • creatininerequired
    lab • used at CONTEXT
    End-organ damage marker; renal function gates DOAC dosing for mural thrombus and EGPA renal involvement screen
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Marker of myocardial injury; trend with steroid response
  • bnp_ntprobnprequired
    lab • used at INITIAL_WORKUP
    HF severity marker; trend with response
  • parasite_serologies_and_stool_oprequired
    lab • used at INITIAL_WORKUP
    MANDATORY before steroid initiation — strongyloides serology (steroids cause hyperinfection syndrome → fatal); also toxocara, schistosoma, trichinella per exposure history
  • anca_panelrequired
    lab • used at INITIAL_WORKUP
    ANCA positivity (typically MPO-ANCA) supports EGPA diagnosis (Churg-Strauss); changes treatment to add cyclophosphamide/rituximab
  • fip1l1_pdgfra_mutation_test
    lab • used at BRANCHING_WORKUP
    Identifies clonal HES treated with IMATINIB rather than just steroids; dramatic response to imatinib if positive (Cools NEJM 2003)
  • medication_review_for_hypersensitivity_drugsrequired
    lab • used at CONTEXT
    Identify offending drug (antibiotics, antipsychotics, anticonvulsants, allopurinol) — discontinuation is a critical treatment step
  • echorequired
    imaging • used at INITIAL_WORKUP
    Wall thickening, LV dysfunction, mural thrombus from endocardial damage, pericardial effusion screen
  • ecgrequired
    imaging • used at INITIAL_WORKUP
    T-wave inversions, PR depression (pericardial involvement), heart block (eosinophilic infiltrate of conduction system); rule out STEMI
  • cmrrequired
    imaging • used at BRANCHING_WORKUP
    Lake Louise criteria + LGE (subendocardial/endocardial-predominant pattern in eosinophilic myocarditis vs subepicardial in viral); helps avoid biopsy in some cases
  • endomyocardial_biopsyrequired
    imaging • used at BRANCHING_WORKUP
    GOLD STANDARD — eosinophilic infiltrate + necrosis + endomyocardial fibrosis; differentiates from giant-cell, lymphocytic; determines etiology subtype

12-phase flow (11)

  1. 1FRAME
    Confirm eosinophilic myocarditis with cardiogenic shock — peripheral eosinophilia >1500/µL + LV dysfunction + shock physiology + ESC 2013 myocarditis criteria; identify etiology (drug-induced/parasitic/HES/EGPA/idiopathic)
    inputs: cbc_with_differential, echo
    advance: Eosinophilic myocarditis confirmed + CS overlay documented + etiology workup launched
  2. 2ENTRY
    CS team activation; rapid diagnostic workup including PARASITE EXCLUSION (mandatory before steroids); medication review; consider EMB if etiology unclear or steroid response inadequate
    inputs: sbp, lactate, cbc_with_differential
    advance: CS team activated + parasite workup launched + medication review complete
  3. 3CONTEXT
    Drug history (antibiotics, antipsychotics, anticonvulsants, allopurinol — DRESS triggers); travel history (parasites); asthma/sinusitis/atopy (EGPA); rash + lymphadenopathy + fever (DRESS); prior eosinophilia history (HES); comorbidities; baseline meds
    inputs: creatinine, medication_review_for_hypersensitivity_drugs
    advance: Etiology context complete
  4. 4RED_FLAGS
    Strongyloides hyperinfection risk if steroids without parasite exclusion (FATAL); STEROID-REFRACTORY progression to RCM (Loeffler endocarditis); HES with FIP1L1-PDGFRA discovered (imatinib responsive); drug-induced DRESS overlay with multi-organ failure; refractory ventricular arrhythmias from conduction system infiltrate
    inputs: sbp
    actions: cardiogenic_shock, cardiac_tamponade
    advance: Red flags screened + parasite workup pending result before steroids
  5. 5INITIAL_WORKUP
    CBC with differential (absolute eosinophil count), troponin, BNP, BMP, lactate, ABG, CXR, ECG, echo, CMR, parasite serologies + stool O&P, ANCA panel, IgE level, total tryptase (mast cell disorders), peripheral smear, LDH, B12 (HES markers)
    inputs: cbc_with_differential, troponin, bnp_ntprobnp, lactate, ecg, echo, cmr, parasite_serologies_and_stool_op, anca_panel
    actions: cardiogenic_shock, panel.cardiac, panel.renal, panel.abg, panel.coag
    advance: Diagnostic anchors documented
  6. 6BRANCHING_WORKUP
    Endomyocardial biopsy (GOLD STANDARD — eosinophilic infiltrate + necrosis); FIP1L1-PDGFRA mutation testing if HES suspected; ANCA confirmation if EGPA suspected; bone marrow biopsy if HES with myeloproliferative features; consider MIBG/PET for EGPA staging
    inputs: endomyocardial_biopsy
    advance: Etiology confirmed + treatment-targeted pathway selected
  7. 7RISK_STRATIFICATION
    SCAI 2022 stage; CardShock prognosis (Harjola EHJ 2015 PMID 26333869); steroid responsiveness gate (24–72 h response is positive prognostic indicator); arrhythmic risk per conduction system involvement on ECG/biopsy
    inputs: sbp, lactate
    advance: Risk stratified
  8. 8TREATMENT
    STEROIDS as foundation AFTER parasite exclusion: methylprednisolone 1 g IV daily × 3–5 d → prednisone 1 mg/kg/d taper. ETIOLOGY-SPECIFIC additions: imatinib 100–400 mg/d if FIP1L1-PDGFRA+; mepolizumab 300 mg SC q4wk if HES steroid-refractory; cyclophosphamide/rituximab + steroids if EGPA; albendazole/ivermectin/praziquantel if parasitic; DISCONTINUE offending drug if hypersensitivity/DRESS. Standard CS support: cautious NE for MAP ≥65; MCS bridge per SCAI 2022 if SCAI C+. Mural thrombus prophylaxis (warfarin INR 2-3 or apixaban 5 mg BID × 3 mo) if EF<35 + endocardial involvement
    inputs: sbp, lactate
    actions: cardiogenic_shock
    advance: Etiology-specific therapy started + steroid response monitoring underway
  9. 9DISPOSITION
    CICU at MCS-capable center if SCAI C+; advanced-HF center transfer for refractory; rheumatology consult if EGPA/HES; hematology consult if HES; ID consult if parasitic
    advance: Disposition assigned + multidisciplinary team mobilised
  10. 10MONITORING
    A-line, central line, lactate clearance, urine output, telemetry (heart block + arrhythmic surveillance from conduction system involvement), DAILY EOSINOPHIL COUNT (steroid response marker — should drop within 24–48 h), serial echo q24–48h for LV recovery, troponin trend
    inputs: cbc_with_differential, lactate
    actions: panel.cardiac, panel.renal
    advance: Monitoring + reassessment cadence set
  11. 11FOLLOWUP
    Repeat echo at 4–8 wks for LV recovery assessment; CMR at 3 mo for endocardial fibrosis screen (Loeffler endocarditis progression); steroid taper over 6–12 mo (slow taper given recurrence risk); long-term mepolizumab/imatinib if HES; rheumatology long-term care if EGPA; ICD evaluation if persistent severe LV dysfunction or refractory VT/VF; recurrence ~25% if rapid steroid taper
    advance: Recovery echo + steroid taper plan + etiology-specific long-term plan documented