Cardiac Arrhythmias as Initial Presentation of Sarcoidosis

Abstract

SESSION TITLE: Student/Resident Case Report Poster - Cardiovascular Disease I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Cardiac sarcoidosis is an infiltrative disease which is usually clinically silent but occasionally may be the first manifestation of sarcoidosis even in the absence of overt systemic involvement. It frequently presents with structural and conduction abnormalities including supraventricular and ventricular arrhythmias, myocardial damage simulating infarction, heart failure, cardiomyopathy, valvular heart disease, and sudden death. CASE PRESENTATION: A 33 year old African American female presented to emergency room with episodes of palpations. Her exam and laboratory work up were unremarkable. Electrocardiogram showed sinus arrhythmia with pre-ventricular contractions and she was started on Metoprolol. She was having non-sustained ventricular tachycardia (NSVT) which subsequently became sustained requiring Lidocaine with conversion to sinus tachycardia. Echocardiography was normal. However she continued to have NSVT which raised a concern for an infiltrative process. She had cardiovascular magnetic resonance imaging (CMRI) which showed a large area of delayed mid myocardial enhancement at the inferolateral, basal, mid portion and apical wall with 25% viability and hypokinesis. A high resolution computed tomography of her chest was unrevealing. Endomyocardial biopsy (EMB) was considered as she had no other obvious manifestation of sarcoidosis but was not done as her lesions were patchy. She eventually got an Implantable Cardioverter-Defibrillator and was discharged on Metoprolol. DISCUSSION: The diagnosis and management of cardiac sarcoidosis is a major challenge especially in the absence of systemic manifestations. Findings on electrocardiogram and echocardiogram are nonspecific; CMRI and even positron emission tomography (PET) features may be suggestive but are not diagnostic. EMB which demonstrates noncaseating epithelioid granulomas lacks sensitivity as it may miss the lesion and is usually reserved for patients without histologic confirmation from another source. The ability to diagnose this promptly, predict progression and prognosis, and intervene before a fatal cardiac event, deserves further investigation. The use of steroids lack confirmatory randomized clinical trials. A low threshold for invasive procedures is suggested due to the risk of sudden death. CONCLUSIONS: In young patients presenting with cardiac arrhythmias, sarcoidosis should be considered even in the absence of systemic involvement as this might be a herald sign for an opportunity to intervene and prevent impending sudden cardiac death. Reference #1: Schulte W, Kirsten D, Drent M, Costabel U.Cardiac involvement in sarcoidosis. Eur Respir Mon. 2005;32:130 Reference #2: Patel MR, Cawley PJ, Heitner JF, Klem I, Parker MA, Jaroudi WA, et al. Detection of myocardial damage in patients with sarcoidosis. Circulation. 2009;120(20):1969. Reference #3: Nery PB, Leung E, Birnie DH. Arrhythmias in cardiac sarcoidosis: diagnosis and treatment. Curr Opin Cardiol. 2012;27(2):181. DISCLOSURE: The following authors have nothing to disclose: Chukwunweike Nwosu, Deepika Nandiraju, Danila Deliana, Joseph Neri No Product/Research Disclosure Information