IMAGES IN PEDIATRIC CARDIOLOGY Loeffler’s Syndrome Nidhi Narula • Rajiv Mahajan • Manojkumar Rohit Received: 16 March 2010 / Accepted: 5 May 2010 / Published online: 23 May 2010 Ó Springer Science+Business Media, LLC 2010 A 9-year-old boy presented to the emergency room in shock with a 3-month history of low-grade fever and vomiting. He had no history of heart disease or contact with animals. The boy had tachycardia, tachypnea, a systolic blood pressure of 70 mmHg, pedal edema, hepatomegaly, and prominent neck veins. Precordial examination showed cardiomegaly, a S4 gallop rhythm, and a pansystolic murmur at the left lower sternal border. Radiography showed an enlarged heart. Echocardiography showed a dilated and noncollapsing inferior vena cava and a dilated right atrium. There was a gross encroachment into the right ventricular cavity by an echo-dense mass throughout the cardiac cycle (Fig. 1) and further, although less extensive, involvement of the left ventricle (Fig. 2). There was low- pressure severe tricuspid regurgitation with a normally positioned tricuspid valve and mild mitral regurgitation. The use of M-mode showed a fractional shortening of 20% and an ejection fraction of 50%. There was mild pericardial effusion but no pericardial thickening (see supplementary material 1, 2, 3, and 4). The echo findings were interpreted as endomyocardial fibroelastosis. Later, a complete review of the patient’s admission blood count showed leukocytosis (56,000/cubic millimeter or 56 9 10 9 /litre) with an abnormally elevated level of peripheral eosinophils, an absolute count of 4,480/ cubic millimeter, and an erythrocyte sedimentation rate of 68 millimeter/hour. In view of the elevated absolute eosinophil count, Loeffler’s endocarditis was diagnosed, and the patient was managed accordingly. The patient was started on immu- nosuppressive therapy with prednisolone. The anticipated appropriate decline in the eosinophilic count was noted to be within the normal range. The boy unfortunately dis- continued prednisone due to weight gain and was lost to follow-up evaluation. Loeffler’s endocarditis is a condition in which mature eosinophils infiltrate and damage the endocardium and myocardium [3]. This syndrome shows persistent apical obliteration, valve involvement, and progressive features of a restrictive cardiomyopathy apart from hematologic abnormalities [2]. With the use of echocardiography, 40% to 50% of patients with Loeffler’s syndrome are shown to have some form of cardiac involvement [1]. The reported patient demonstrated an interesting case of Loeffler’s syndrome with cardiac involvement well delineated by echocardiographic evaluation. Electronic supplementary material The online version of this article (doi:10.1007/s00246-010-9732-7) contains supplementary material, which is available to authorized users. N. Narula (&) Á R. Mahajan Á M. Rohit Department of Cardiology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India e-mail: drnidhi2003@yahoo.co.in 123 Pediatr Cardiol (2010) 31:931–932 DOI 10.1007/s00246-010-9732-7