Heart in the crossfire, from epsilon to beyond: cardiac sarcoidosis—a case report

Sarcoidosis is a great mimicker of various medical conditions, which leads to obstacles in early diagnosis and appropriate timely management.

A 66-year-old Indian female with metabolic syndrome was initially treated for decompensated liver disease. Her baseline electrocardiogram showed right bundle branch block with a first-degree heart block. She presented 3 months later with angina and heart failure (HF) symptoms, complicated with ventricular tachycardia (VT) treated with i.v. amiodarone and anti-failure medication. Her coronary angiogram revealed mild disease, and her echocardiography showed a mildly reduced ejection fraction (EF) of 45% with regional wall motion abnormalities. Cardiac magnetic resonance imaging (CMR) revealed non-specific left ventricular (LV) patchy mid-wall to epicardial late gadolinium enhancement. Endomyocardial biopsy was complicated with cardiac tamponade and required pericardiocentesis followed by dual-chamber implantable cardioverter-defibrillator (ICD) later. Unfortunately, biopsy result was inconclusive, and serum angiotensin-converting enzyme was within the normal range. She had multiple admissions for the past 2 years for recurrent VT and decompensated HF despite the optimization of ICD setting and guideline-directed medical therapy. Repeated echocardiogram revealed similar EF with thinning of the LV basal septal segment. Her positron emission tomography (PET) scan (Tc-99 m) showed diffuse uptake at the LV myocardium and supraclavicular/mediastinal/abdominopelvic lymph nodes with a mismatch of fluorodeoxyglucose uptake at the basal–inferolateral segment (non-specific). Lymph node biopsy revealed chronic non-caseating granulomatous inflammation. Clinical diagnosis of cardiac sarcoidosis was made based on a histologic diagnosis of extracardiac sarcoidosis with cardiomyopathy/ventricular arrhythmia combined with PET/CMR findings.

Cardiac sarcoidosis can have a myriad of symptoms, which may mimic several other disorders leading to a diagnostic challenge.