Increased fetal endocardial echogenicity mimicking endocardial fibroelastosis following maternal organophosphorus poisoning and its complete regression in utero
A 23-year-old primigravida at 20 weeks of gestation was hospitalized, following suicidal attempt by ingestion of organophosphorus pesticide (carbofuran). She was treated with antidote, corticosteroid steroid, and supportive measures. Following recovery after 2 weeks, she was referred for a targeted scan for anomalies at 22 weeks of gestation.\nAll fetal routine biometric parameters were normal on routine scanning. Fetal echocardiography showed normal cardiac situs, size, and axis. Both ventricular and interventricular septal endocardial surfaces showed diffuse hyperechoic thickening []. The interventricular septum was pearly white []. This pearly white lining was extending along the crux and atrioventricular valves []. These changes were more involving the left ventricle and the mitral valve. The abnormally curved mitral leaflets had rolled tips []. There was mild degree incompetence of the mitral valve. The proximal outflow tracts, mainly up to the semilunar valves, were also brighter with normal crossing, dimensions, and flow []. The aortic and pulmonary artery valves showed no evidence of stenosis or incompetence. Pulsed Doppler study (cursor directed through the left ventricle along the junction of the anterior leaflet of the mitral valve and left ventricular outflow tract) showed E/A ratios of mitral and tricuspid valves below the 2.5th percentile (0.41 and 0.45, respectively) for this period of gestation.[] The E/A ratio of the atrioventricular valves is calculated by dividing the peak velocity of “E” wave (due to early diastolic filling of the ventricle) by the peak velocity of the “A” wave (due to late diastolic filling of the ventricle from atrial contraction).\nThe myocardial performance index (MPI), otherwise known as Tei index (TI), for the left ventricle was more (0.71)[] than the normal value expected at this gestational age (average value at this age is 6). There were no significant Doppler spectral changes of the inferior vena cava (such as reversal of A wave in the inferior vena cava or hepatic veins) or umbilical vein (biphasic rather than triphasic spectral pattern and umbilical venous pulsations) to suggest impending cardiac failure. The routine serum immunological studies for maternal viral infections were normal.\nReassessment at 26 weeks of gestation showed non-progressive echocardiographic abnormalities and mild mitral incompetence as before. The endocardial thickening and hyperechogenicity were persisting and the ventricular wall thickness was normal. Follow-up echocardiography at 36 weeks of gestation showed normal fetal cardiac chambers and outflow tracts. The endocardial thickening and hyperechogenicity had completely regressed by this time. The myocardial contractions and ventricular fractional shortening were normal. The atrioventricular valves showed no stenosis or incompetence now. The fetal growth parameters and biophysical score were normal. She delivered a normal male baby by term with normal echocardiographic features.