Sarcoidal Pericardial Effusion Masquerading As Acute Myocardial Infarction

Abstract

Sarcoidosis is a multisystemic granulomatous disease, with varying modes of presentation. Pericardial sarcoidosis is rare and cardiac tamponade secondary topericardial sarcoidosis is very uncommon. We present a case of a young man who presented with signs and symptoms suggestive of acute myocardial infarction who was thrombolysed but subsequently died. The cause of his death was made apparent on the post mortem examination which revealed a massive pericardial effusion and a necrotic mature mediastinal teratoma. INTRODUCTION We discuss one case of a young man with symptoms and electrocardiographic evidence of acute myocardial infarction who was thrombolysed but later died. Postmortem findings were suggestive of widespread sarcoidosis with a massive pericardial effusion and a necrotic mature mediastinal teratoma. CASE REPORT A 43-year-old obese man with type 2 diabetes mellitus was brought with a 2 hour history of central crushing chest pain and shortness of breath. On initial assessment his blood pressure was 150/90 mm Hg, equal in both arms with a pulse of 90 per minute, sinus rhythm and respiratory rate of 24/min. Cardiovascular examination was normal. An ECG performed in the ambulance showed 1-2 mm ST elevation in the inferior leads -II, III, aVF. (Figure1). He was transferred to the coronary care unit where he was thrombolysed with reteplase. Subsequent ECG's performed in the CCU showed near normalization of the ST segments. AP view of the chest radiograph showed a prominent right hilum and patchy consolidation of the left upper and lower lobes. After remaining stable and pain free for 4-5 hours, his condition deteriorated and he became hypotensive, tachypnoeic and acidotic. An ECG at this stage showed a sinus tachycardia of 120 per minute. He developed extensive haemorrhagic mottling of his back and rapidly succumbed to the cardiogenic shock despite attempt at resuscitation. Post mortem study of the gross specimen of the heart showed a 650 ml, blood stained pericardial effusion. Extensive loose pericardial adhesions were also seen. There wasminimal (20%) coronary atherosclerosis and no evidence of scarring or acute myocardial infarction. The ascending and descending aorta were unremarkable without evidence of dissection. In the upper mediastinum, a 7 cm cystic, necrotic tumour containing blood adherent to the left lung and superior pericardium was seen. Extensive hilar lymphadenopathy was also seen. On histopathological examination, non caseating granulomas and inflammation of the lungs, mediastinal lymph nodes, myocardium, epicardium (Figure 2a) and liver were seen suggestive of extensive multisystem sarcoidosis. The mediastinal mass showed an extensively necrotic and inflamed teratoma with cartilage.(Figure 2b). Figure 1 Electrocardiogram on admission showing ST segment elevation in inferior leads, II, III, aVF Sarcoidal Pericardial Effusion Masquerading As Acute Myocardial Infarction 2 of 4 Figure 2 Histopathological section showing epicardium and outer layer of myocardium. There is a well defined granuloma consistent with sarcoidosis in the epicardial fat. Section of the mediastinal tumour showing a necrotic mass. Preserved areas of the tumour show mature elements including cartilage. These features are those of mature mediastinal teratoma. (Haematoxylin and eosin x 40).