Heart in the crossfire, from epsilon to beyond: cardiac sarcoidosis—a case report

TL;DR

A 66-year-old woman with cardiac sarcoidosis presented with heart failure and arrhythmias, and was diagnosed using a combination of imaging and biopsy findings.

Contribution

This case report highlights the diagnostic challenges and clinical presentation of cardiac sarcoidosis.

Findings

The patient exhibited symptoms of heart failure and ventricular tachycardia, with inconclusive biopsy results.

PET scan and CMR findings, along with lymph node biopsy, supported a clinical diagnosis of cardiac sarcoidosis.

The case illustrates the difficulty in diagnosing cardiac sarcoidosis due to its mimicking of other conditions.

Abstract

Sarcoidosis is a great mimicker of various medical conditions, which leads to obstacles in early diagnosis and appropriate timely management.

A 66-year-old Indian female with metabolic syndrome was initially treated for decompensated liver disease. Her baseline electrocardiogram showed right bundle branch block with a first-degree heart block. She presented 3 months later with angina and heart failure (HF) symptoms, complicated with ventricular tachycardia (VT) treated with i.v. amiodarone and anti-failure medication. Her coronary angiogram revealed mild disease, and her echocardiography showed a mildly reduced ejection fraction (EF) of 45% with regional wall motion abnormalities. Cardiac magnetic resonance imaging (CMR) revealed non-specific left ventricular (LV) patchy mid-wall to epicardial late gadolinium enhancement. Endomyocardial biopsy was complicated with cardiac tamponade and required pericardiocentesis followed by dual-chamber implantable cardioverter-defibrillator (ICD) later. Unfortunately, biopsy result was inconclusive, and serum angiotensin-converting enzyme was within the normal range. She had multiple admissions for the past 2 years for recurrent VT and decompensated HF despite the optimization of ICD setting and guideline-directed medical therapy. Repeated echocardiogram revealed similar EF with thinning of the LV basal septal segment. Her positron emission tomography (PET) scan (Tc-99 m) showed diffuse uptake at the LV myocardium and supraclavicular/mediastinal/abdominopelvic lymph nodes with a mismatch of fluorodeoxyglucose uptake at the basal–inferolateral segment (non-specific). Lymph node biopsy revealed chronic non-caseating granulomatous inflammation. Clinical diagnosis of cardiac sarcoidosis was made based on a histologic diagnosis of extracardiac sarcoidosis with cardiomyopathy/ventricular arrhythmia combined with PET/CMR findings.

Cardiac sarcoidosis can have a myriad of symptoms, which may mimic several other disorders leading to a diagnostic challenge.

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