APCU25MPC3 An under-recognized entity – cardiac sarcoidosis

Introduction Cardiac sarcoidosis (CS), an infiltrative cardiomyopathy that results from granulomatous inflammation of the myocardium. CS is more prevalent than previously recognized. Studies suggest that approximately 5-10% of patients with sarcoidosis exhibit cardiac involvement, but the true prevalence may be higher due to underdiagnosis. Based on imaging and autopsy findings CS occurs approximately 25% of patient with sarcoidosis. This discrepancy highlights the importance of awareness among HCP regarding the potential for CS in patients diagnosed with sarcoidosis.Objective To illustrate the diagnostic pathway to diagnose a suspected cardiac sarcoidosisCase Presentation A 60-year-old man with unremarkable medical history was seen at the cardiology clinic presented with sudden onset of left sided chest pain and palpitations. Initial physical examination was unremarkable with mildly elevated high-sensitivity troponin T level. His ECG showed RBBB with occasional PVC. His initial transthoracic echocardiography (TTE) showed LVEF of 50%, hypokinesia over mid anterior and septal walls. Subsequently, Myocardium perfusion scan showed infarcted apex, anterior and inferior wall. Normal coronaries noted in COROS. There was low burden of PVC with non-sustained ventricular tachycardia on Holter. Repeated TTE showed reduced LVEF of 39%, dilated Left ventricular, globally hypokinetic walls, abnormal structure seen at RVOT. Cardiac MRI scan showed patterns of diffuse enhancement at LV septum, suspicious of infiltrative disease of CS with LV clot. His Serum ACE within normal range, 30u/L. A PET scan revealed cardiac granulomatous disease without evidence of other organ involvement. Patient was started with prednisolone in addition to anticoagulant therapy.Result This patient’s case demonstrates the initial manifestation of sarcoidosis can be CS without other organ involvement. CS inherently silent until the disease progression is severe enough to cause clinical manifestations. CS commonly missed especially in established systemic sarcoidosis as well. Adequate and promptly diagnosis are important in detecting CS in order to prevent further complications from this disease, which is mostly poor prognosis and high mortality. The updated guidelines allow diagnosis of CS without a myocardial biopsy. Additionally, this case demonstrates how the multiple diagnostic criteria for CS have yet come to a clear consensus.