PMC10484760_01
Twelve-lead electrocardiogram (ECG) findings during chest pain attack. The ECG showed ST-segment elevation in aVR and ST-segment depression in I, II, aVL, and aVF.
1349-7235-62-2389-g001.jpg
PMC10484760_01_1349-7235-62-2389-g001.jpg
g001
The electrocardiogram (ECG) in the emergency room showed ST-segment elevation in aVR, and ST-segment depression in I, II, aVL, and aVF (Fig. 1).
Imaging studies on admission. A: Computed tomography (CT) of the paranasal sinus showed sinusitis (arrows). B: Chest CT on admission showed reticular shadows around broncho-vascular bundles in the bilateral lower lobes and bronchial wall thickening (arrows).
1349-7235-62-2389-g002.jpg
PMC10484760_01_1349-7235-62-2389-g002.jpg
g002
Chest computed tomography (CT) also showed multiple tiny lung infiltrates and a ground-glass appearance consistent with vasculitis processes at the bilateral lower lobe (Fig. 2).
A coronary angiogram obtained during the ergonovine provocation test (A: control, B: ergnovine). A: Before the ergonovine provocation test of coronary artery spasm. No significant stenosis in the right coronary artery. B: After intra-coronary infusion of ergonovine (20 mug), a severe coronary artery spasm was provoked in the right coronary artery.
1349-7235-62-2389-g003.jpg
PMC10484760_01_1349-7235-62-2389-g003.jpg
g003
CSA was suspected and 20 mug of ergonovine was loaded to induce coronary artery spasm (Fig. 3).
The clinical course after late March 2020. The patient noticed persistent chest pain attacks for 10-15 minutes every day in early April 2020. Marked elevation of eosinophil count was observed, and the diagnosis of eosinophilic granulomatosis with polyangiitis (EGPA) with coronary spastic angina was made. He was started on high-dose prednisolone (PSL) therapy of 60 mg (1 mg/kg) and chest pains improved. Following PSL administration, the eosinophil count markedly decreased, and angina attacks disappeared. When PSL was tapered to 12.5 mg, he occasionally experienced mild chest pain with slight progression of eosinophilia. The administration of 300 mg mepolizumab kept the eosinophils count under 100 cells/muL. Two years after the onset of EGPA, PSL was tapered to 6 mg, but there was no recurrence of chest pain or discomfort.
1349-7235-62-2389-g004.jpg
PMC10484760_01_1349-7235-62-2389-g004.jpg
g004
In addition to PSL, we initiated treatment with 300 mg mepolizumab to safely taper the PSL dose (Fig. 4).