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International Journal of Cardiovascular Sciences. 2016;29(6):520-523 520

CASE REPORT

Acute as a Rare Presentation of Cardiac Involvement in Ioannis Bostanitis,1 Stella-Lida Papadopoulou,1 Maria Tsalidou,1 Konstantinos Triantafyllou,1 Chrysafios Girasis2 Department of - General Hospital of Katerini;1 Department of Interventional Cardiology - Euromedica General Clinic Thessaloniki2 - Greece

Introduction showed a normal cardiothoracic ratio and hilar enlargement, and the 12-lead electrocardiogram (ECG) Sarcoidosis is a chronic systemic disease without showed widespread concave ST-segment elevation and any identified etiology. In general, it affects the PR-segment depression throughout most of the limb lungs and lymph nodes, but can implicate any leads and precordial leads (Figure 1). Transthoracic other organ. Cardiac involvement in patients with echocardiography showed a normal myocardial systemic sarcoidosis is usually the cause of death.1 appearance, LV diastolic dysfunction, and the presence Usually, patients present with complete block, of only minimal (6 mm-thick) . , ventricular (VT), Laboratory studies on admission revealed elevated congestive , and/or sudden death.2 white blood cell count (WBC: 12,680/μL) and elevated The myocardium and, to a lesser extent, the serum C-reactive protein (CRP) level (7.69 mg/dL); are usually involved. Pericardial involvement often high-sensitive troponin-I and creatine kinase levels presents as moderate to large pericardial effusion were normal (4.0 pg/ml and 101 IU/L respectively). 3 detected in echocardiography. We here present a Other diagnostic evaluations for viruses and thyroid case of symptomatic , which is a rare function were negative. manifestation of cardiac involvement in sarcoidosis.1,4,5 The patient was hospitalized and started on intravenous prednisolone 75 mg/d and oral colchicine Case Report 1 mg/d. Three days later, he was discharged symptom-free on oral colchicine 1 mg/d and oral A 65-year-old male patient arrived at our emergency prednisolone 10 mg/d gradually tapered over the department with dull oppressive retrosternal chest following weeks. pain without other accompanying symptoms. th The pain was exacerbated with inspiration, and had At the 10 day of follow-up, laboratory tests had been started 14 hours before. The patient had a medical normalized (WBC: 9,200/μL and CRP: 0.12 mg/dL), history of pulmonary sarcoidosis diagnosed 10 years ST‑segment elevations had largely resolved and there before (for which he was on a regimen of low was no pericardial fluid in the echocardiogram. doses of oral prednisolone), arterial hypertension The patient was referred for cardiac magnetic and a hemorrhagic stroke 18 years ago. At initial resonance (CMR) study with gadolinium, which presentation, blood pressure was 130/80 mmHg, heart offers the advantage of high sensitivity and spatial rate was 90 beats/min, oxygen saturation 95% and resolution, in addition to no radiation exposure.7 temperature was 36.8°C. A pericardial friction rub Since this imaging technique was not available was audible without any further pathological sounds in our hospital, the patient underwent CMR in a on cardiac or respiratory auscultation. Chest X-Ray tertiary center at a later stage, after six weeks under treatment, which ruled out granulomatous infiltration of the myocardium (Figure 2). Furthermore, the small Keywords pericardial effusion had resolved completely, which Pericarditis; Sarcoidosis, Pulmonary; Hypertension; was in accordance with the normalized inflammation Stroke. markers and the patient’s asymptomatic condition.

Mailing Address: Stella-Lida Papadopoulou Thermaikou, 49. Postal Code: 55133, Thessaloniki - Greece E-mail: [email protected]

DOI: 10.5935/2359-4802.20170009 Manuscript received September 21, 2016; revised manuscript October 11, 2016; accepted November 29, 2016. Int J Cardiovasc Sci. 2016;29(6):520-523 Bostanitis et al. Case Report Pericarditis in sarcoidosis 521

Figure 1 – Panel A: ECG from 1 year ago. Panel B: ECG at admission. Concave ST-segment elevations and PR-segment depressions were recorded throughout most of the limb leads (II, III, aVF) and precordial leads (V2-6), with reciprocal PR elevation and ST depression in aVR. Panel C: ECG at 10- days follow-up.

Discussion validated guidelines, and our experience relies mostly on published case reports and small series of patients Acute pericarditis with or without pericardial rather than on large population studies. effusion is an inflammatory pericardial disease The early and reliable diagnosis of cardiac involvement 7 considered idiopathic in approximately 80% of cases. remains extremely difficult, and even subtle cardiac Secondary causes include several systemic diseases, symptoms require thorough investigation by the clinician. such as systemic erythematosus, Sjogren’s Cardiac involvement in pulmonary sarcoidosis is syndrome, rheumatoid arthritis and scleroderma, and, associated with a poor prognosis, especially once patients more rarely, sarcoidosis. become symptomatic.9 Conversely, asymptomatic Only 5% of patients with systemic sarcoidosis patients have a good prognosis; therefore, early diagnosis develop cardiac symptoms; however, pathology studies and treatment are crucial. Physicians must be aware of reveal myocardial granulomas in 20-30% of patients.8 silent cardiac involvement in patients with pulmonary Pericardial involvement is considered rare even if sarcoidosis, and thus, these patients should be routinely widespread myocardial infiltration has occurred.2 monitored both clinically and with an ECG, reserving Symptomatic acute pericarditis without pericardial echocardiography, and when necessary CMR, for cases effusion is seldom observed in sarcoidosis.4 raising a higher degree of suspicion.6 However, unlike sarcoidosis with the involvement Considering cardiac sarcoidosis is associated with of other organs, cardiac sarcoidosis carries an increased an increased risk of sudden death, especially in case of risk of sudden death and can be challenging to diagnose. myocardial infiltration, several therapeutic strategies Due to the rarity of the condition, there are no clearly should be considered. Early treatment with corticosteroids Bostanitis et al. Int J Cardiovasc Sci. 2016;29(6):520-523 522 Pericarditis in sarcoidosis Case Report

Figure 2 – Cardiac magnetic resonance study showing normal myocardial appearance.

or other immunosuppressant agents may prevent the Acknowledgements progression of cardiac involvement. Certain cases of high-grade AV conduction block or other types of We would like to acknowledge the contribution of the bradyarrhythmia justify implantation.10 staff of the Cardiology department to the work presented. Moreover, life-threatening ventricular triggered by myocardial infiltrates may require implantable Author contributions cardioverter-defibrillator therapy for primary prevention of sudden cardiac death in selected high-risk patients.10 Conception and design of the research: Bostanitis I, Papadopoulou SL. Acquisition of data: Bostanitis I, Conclusion Papadopoulou SL, Tsalidou M, Triantafyllou K. Analysis and interpretation of the data: Bostanitis We here present a case of acute pericarditis, which I, Papadopoulou SL, Triantafyllou K, Girasis C. is an unusual cardiac manifestation of sarcoidosis. Writing of the manuscript: Bostanitis I, Papadopoulou The present case emphasizes that early diagnosis of SL, Tsalidou M, Girasis C. Critical revision of the cardiac involvement remains challenging and routine manuscript for intellectual content: Bostanitis I, screening of pulmonary sarcoidosis patients is pivotal Papadopoulou SL, Tsalidou M, Triantafyllou K, to monitor the course of the disease. Girasis C. Int J Cardiovasc Sci. 2016;29(6):520-523 Bostanitis et al. Case Report Pericarditis in sarcoidosis 523

Potential Conflict of Interest Study Association No potential conflict of interest relevant to this article This study is not associated with any thesis or was reported. dissertation work.

Sources of Funding There were no external funding sources for this study.

References

1. Roberts WC, McAllister HA Jr, Ferrans VJ. Sarcoidosis of the heart. of pericardial diseases: The Task Force for the Diagnosis and A clinicopathologic study of 35 necropsy patients (group 1) and review Management of Pericardial Diseases of the European Society of of 78 previously described necropsy patients (group 11). Am J Med. Cardiology (ESC) Endorsed by: The European Association for Cardio- 1977;63(1):86-108. Thoracic Surgery (EACTS). Eur Heart J. 2015;36(42):2921-64.

2. Sekhri V, Sanal S, Delorenzo LJ, Aronow WS, Maguire GP. Cardiac 8. Silverman KJ, Hutchins GM, Bulkley BH. Cardiac sarcoid: sarcoidosis: a comprehensive review. Arch Med Sci. 2011;7(4):546-54. a clinicopathologic study of 84 unselected patients with systemic sarcoidosis. Circulation. 1978;58(6):1204-11. 3. Houston BA, Mukherjee M. Cardiac sarcoidosis: clinical manifestations, imaging characteristics, and therapeutic approach. Clin Med Insights 9. Smedema JP, Snoep G, van Kroonenburgh MP, van Geuns RJ, Dassen Cardiol. 2014;8(Suppl 1):31-7. WR, Gorgels AP, et al. Cardiac involvement in patients with pulmonary sarcoidosis assessed at two university medical centers in the Netherlands. 4. Doughan AR, Williams BR. Cardiac sarcoidosis. Heart. 2006;92(2):282-8. Chest. 2005;128(1):30-5.

5. Wyplosz B, Marijon E, Dougados J, Pouchot J. Sarcoidosis: an unusual 10. Epstein AE, DiMarco JP, Ellenbogen KA, Estes NA 3rd, Freedman RA, cause of acute pericarditis. Acta Cardiol. 2010;65(1):83-4. Gettes LS, et al. ACC/AHA/HRS 2008 Guidelines for Device-Based 6. Smedema JP, Snoep G, van Kroonenburgh MP, van Geuns RJ, Dassen WR, Therapy of Cardiac Rhythm Abnormalities: a report of the American Gorgels AP, et al. Evaluation of the accuracy of gadolinium‑enhanced College of Cardiology/American Heart Association Task Force on cardiovascular magnetic resonance in the diagnosis of cardiac Practice Guidelines (Writing Committee to Revise the ACC/AHA/ sarcoidosis. J Am Coll Cardiol. 2005;45(10):1683-90. NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices) developed in collaboration with the 7. Adler Y, Charron P, Imazio M, Badano L, Baron-Esquivias G, Bogaert J, American Association for Thoracic Surgery and Society of Thoracic et al. 2015 ESC Guidelines for the diagnosis and management Surgeons. J Am Coll Cardiol. 2008;51(21):e1-62.