The specimen shown in the picture (Figure 1) belonged to a 63-year-old female patient who was referred to the Pulmonologist because of a long-standing complaint of cough and dyspnea. She was a hairdresser and had smoked 8 pack years. The work-up, among other examinations, included echocardiogram, cinecoronarioangiography, and cardiac magnetic resonance imaging (MRI), which disclosed the diagnosis of endomyocardial fibrosis. She was submitted to surgical treatment with partial resection of the left ventricle’s endocardium, replacement of the mitral valve by a bioprosthesis, and tricuspid valve repair. Four months later, she was admitted with fever and signs of sepsis, and died soon after. The necropsy and blood culture samples (the results of which were available after death) revealed endocarditis of the mitral prosthesis due to Streptococcus viridans.
Endomyocardial fibrosis (EMF)—also called tropical endomyocardial fibrosis—is a restrictive cardiomyopathy of unknown cause. It is characterized by the deposition of fibrous tissue in the endomyocardium, which leads to a restrictive physiology accompanied by a very poor prognosis without a specific management. This results in demise, which is usually due to heart failure, arrhythmias, and thromboembolism. The disease is endemic in Africa, where the first case was described in 1948 (Uganda),
The etiopathogenesis of EMF remains in the field of hypotheses and far from exact knowledge; therefore, it demands systematic research with the aid of current technologies. The seemingly implicated factors, besides ethnicity, poverty, eosinophilia, autoimmunity, and serotonin, are related to: (i) the excessive immune response against certain parasitic infections; (ii) dietary scarcity (malnutrition); (iii) herbal preparations; and (iv) the use of improperly processed or cooked cassava as the primary source of carbohydrate (because of the ingestion of toxic levels of cyanogenic glycoside).
Typically, EMF presents an insidious onset, usually associated with fever, pancarditis, and eosinophilia, which are morphologically abnormal. This initial active form also presents dyspnea, itching, and periorbital edema.
The most prominent pathological characteristics of EMF