case study by Abigale Clark , BA
DO Candidate 2023 ; Kansas City University , Kansas City , Mo .
Recurrent Cardiac Conduction Abnormalities in a Young Caucasian Female as an Unusual Presentation of Cardiac Sarcoidosis
Abstract
Sarcoidosis is a multisystemic disease of exclusion that may involve virtually any organ in the body , including the heart . Due to the adverse clinical outcomes associated with cardiac involvement , it is crucial for clinicians to keep this diagnosis in mind . Although cardiac sarcoidosis was once considered rare , advancements in imaging studies , such as cardiac magnetic resonance imaging and positron emission tomography , have proved cardiac sarcoidosis more common than previously thought . Cardiac sarcoidosis is commonly asymptomatic , and sudden cardiac death due to fatal conduction system abnormalities often occurs before the diagnosis is made . When symptoms do occur , arrhythmias and congestive heart failure are common clinical presentations . With increasing awareness of the disease and appropriate clinical suspicion , it is possible that cardiac sarcoidosis can be detected and treated early . 1
Case Description
A 23-year-old Caucasian female with a history of recurrent cardiac conduction abnormalities , chest pain , and exertional dyspnea presented for evaluation of ongoing symptoms . Her symptoms began six years prior , when she was diagnosed with SVT and treated with metoprolol . Due to recurrent cardiac palpitations , the patient elected to undergo cardiac ablation . Conduction abnormalities continued to persist sporadically after this procedure , prompting an echocardiogram that revealed mild pericardial effusion as well as mitral and pulmonic valve regurgitation . Cardiac CT was then performed , which incidentally exposed a pulmonary nodule . The nodule was biopsied , and histologic examination of the tissue revealed necrotizing granulomas . Acid fast bacteria and Grocott ’ s methenamine silver stains of the tissue were both negative , and other fungal and mycobacterial causes were ruled out with
Figure 1 . Cardiac Sarcoidosis- PET / CT scan showing patchy hypermetabolism of FDG in a pattern consistent with cardiac sarcoidosis .
extensive serum and urine antigen testing . Serum antibodies for c-ANCA , p-ANCA , PR3-ANCA , and myeloperoxidase were also negative as were rheumatoid factor ( RF ) antibodies , cyclic citrullinated peptide ( CCP ) antibodies , C- reactive protein , and anti-double stranded DNA antibodies . ANA screening was positive , suggesting an autoimmune origin of disease . As a diagnosis of exclusion , sarcoidosis was suspected . The patient began treatment for cardiac sarcoidosis shortly after FDG- PET / CT scan ( Figure 1 ) revealed focal areas of hypermetabolism in a pattern consistent with the disease . The patient was started on a slowly tapering dose of high-dose prednisone and is currently being maintained on methotrexate .
Discussion
Cardiac sarcoidosis is a serious disease that is often found at autopsy due to the lack of early and specific clinical findings . As sudden cardiac death is highly associated with cardiac sarcoidosis , this diagnosis is crucial to keep in mind in patients presenting with arrhythmias and conduction system abnormalities . Though the myocardium and conduction system are most often affected , sarcoidosis is not confined to a specific region of the heart and may manifest clinically in a variety of ways . Cardiac valvular involvement is uncommon , but most commonly manifests as mitral valve regurgitation . If coexisting pulmonary involvement is present , pulmonary hypertension may also lead to pulmonary valve regurgitation . It is important to note that cardiac involvement of sarcoidosis is associated with poor clinical outcomes , making early diagnosis and treatment crucial to the patient ’ s overall prognosis . When other causes of arrhythmia and conduction system abnormalities have been ruled out , cardiac sarcoidosis is an imperative diagnosis for clinicians to keep in mind . 1 , 2
References
1 . Yatsynovich Y , Dittoe N , Petrov M , Maroz N . Cardiac Sarcoidosis : A Review of Contemporary Challenges in Diagnosis and Treatment . Am J Med Sci . 2018 ; 355 ( 2 ): 113-125 . doi : 10.1016 / j . amjms . 2017.08.009
2 . Markatis E , Afthinos A , Antonakis E , Papanikolaou IC . Cardiac sarcoidosis : diagnosis and management . Rev Cardiovasc Med . 2020 ; 21 ( 3 ): 321-338 . doi : 10.31083 / j . rcm . 2020.03.102
180 • The Journal of the Arkansas Medical Society www . ArkMed . org