Case Presentation:
A 51-year-old female with a history of asymptomatic sarcoid presented with one day of shortness of breath and a dry cough. The patient was treated two weeks previously for pneumonia after developing shortness of breath that recurred one day prior to admission. The patient denied any fevers, chills, chest pain, palpitations, and sick contacts. She was afebrile with a blood pressure of 156/88 mmHg and tachycardic to 106 BPM. She had an elevated jugular venous pressure with a regular rate and rhythm and lungs clear to auscultation. She had no edema in her extremeties and her WBC count was 9.3 x 103/ul. She had a left bundle branch block on EKG and an echocardiogram revealed diffuse left ventricular hypokinesis with a 15% ejection fraction. A cardiac MRI illustrated patchy delayed hyperenhancement in a non-coronary distribution consistent with cardiac sarcoidosis, and cardiac catheterization did not show any signs of coronary artery disease. The patient was given furosemide and corticosteroids and discharged home with a marked improvement of her symptoms.
Discussion:
Systolic heart failure is a common condition treated by the medicine hospitalist. This case illustrates the importance of considering alternative etiologies of heart failure such as sarcoidosis. Sarcoid is a non-caseating granulomatous disorder that can affect any organ of the body. Approximately 5% of patients with systemic sarcoid will have cardiac symptoms, with subclinical cardiac involvement in as many as 70%. Cardiac manifestations of sarcoid commonly include heart block (the most common manifestation), heart failure (both systolic and diastolic), and valvular dysfunction. The diagnosis can be made histologically by illustrating the presence of noncaseating granulomas on endomyocardial biopsy. However, biopsy is not indicated if there is histological confirmation of sarcoid from another source. Criteria for diagnosis have been proposed that include advanced AV block, basal thinning of the IV septum, left ventricular ejection fraction of less than 50%, and cardiac gallium uptake. The gallium uptake can be seen as hyperenhancement on cardiovascular MRI that represents granulomatous inflammation within the myocardium. Additionally, studies have shown that one third of patients with cardiac sarcoidosis have no pulmonary findings, making it important to consider this diagnosis even in patients without pulmonary manifestations. Corticosteroids are used to treat cardiac sarcoidosis as they can control the inflammatory reaction in the heart muscle and prevent fibrosis.
Conclusions:
It is important to consider sarcoidosis as an etiology of heart failure even in patients without pulmonary symptoms. Cardiac MRI is helpful in making the diagnosis and corticosteroids are the cornerstone of treatment.