Case Presentation:
A 30‐year‐old woman presented with 1 month of progressively worsening dyspnea on exertion. Her exercise tolerance had decreased; she could barely take a few steps or even pick up her 6‐month old child. She also reported weight loss and persistent cough. She denied fevers, diarrtiea, hemoptysis, arthralgias, rash, and chest pain. She was seen by her primary care provider 2 weeks earlier, diagnosing her with walking pneumonia, and prescribed azithromycin. Her past medical history was unremarkable. She denied alcohol, drug use, and tobacco and did not take any medications. Her heart rate was 146 beats/min, the respiratory rate was 22/min, her temperature was 98.4°F, and her pulse oximetry was 93% on room air. She had muffled heart sounds, and bilateral crackles in the midlung zones. The EKG, CBC. and electrolytes were normal. A chest radiograph demonstrated severe cardiomegaly and bilateral pleural effusions. An echocardiogram showed pericardial effusion with tamponade and depressed systolic function. A pericardiocentesis was performed, and 300 mL of fluid was removed. The fluid cytology revealed a chronic lymphocytic infiltration that was negative for APR. bacteria, fungus, and adenosine deaminase. HIV, PPD, ANA. RPR, cryptococcal antigen, and aspergillus antigen were all negative. A CT of the chest revealed micronodular infiltrates. An endomyocardial biopsy was performed, confirming the presence of nonnecrotizing granulomatous myocarditis. The patient was diagnosed with cardiac sarcoidosis. She was treated with prednisone. 40 mg a day tapering down to 10 mg every other day Her repeat echocardiogram 6 months later revealed a return of normal systolic function,.
Discussion:
Dyspnea and pleural effusions are commonly encountered problems by Ihe hospitalisls. Although infectious and malignant causes of effusions are most common, a systematic approach must be employed to ensure proper diagnosis. In the absence of localizing signs and symptoms or risk factors for malignancy, the pretest probability for granulomatous disease increases. The coexistent pericardial, pleural and lung parenchymal involvement should suggest the diagnosis of sarcoidosis. The most common presentation of sarcoidosis is lymphadenopathy with or without erythema nodosum. Sarcoid can affect the cardiac, pulmonary, gastrointestinal or nervous systems, even in the absence of lymph node or cutaneous involvement. Patients presenting with symptomatic cardiac involvement usually manifest with conduction abnormalities, arrhythmias, and heart failure. However, cardiac sarcoid may involve the pericardial space.
Conclusions:
Although grades 1 and 2 sarcoid can be managed expectantly, any involvement outside of the lungs or skin necessitates corticosteroid therapy. Corticosteroids are considered the mainstay of treatment in patients with cardiac sarcoid. Most trials support starting 40 mg of prednisone a day, tapering the dose over 6‐12 months.
Author Disclosure:
C. Herrington, none.