Cardiac sarcoidosis or giant cell myocarditis? On treatment improvement of fulminant myocarditis as demonstrated by cardiovascular magnetic resonance imaging

Fulminant Cardiac Sarcoidosis Successfully Treated With Aggressive Immunosuppressive Therapy

Background: The clinical course of cardiac sarcoidosis is typically subacute, and fulminant cases requiring mechanical circulatory support are rare. Here, we report the case of a patient with pathologically diagnosed cardiac sarcoidosis who presented with fulminant myocarditis and whose cardiac function was improved by aggressive immunosuppressive therapy based on the treatment of giant cell myocarditis. Case Presentation: A 55-year-old woman presented with progressive dyspnoea and nausea that persisted for 1 month and was eventually diagnosed with acute heart failure. Echocardiography showed a reduced left ventricular ejection fraction with thinning of the basal septal wall. During hospitalisation, she experienced ventricular tachycardia and fibrillation attacks, and bradycardia due to a complete atrioventricular block and sinus dysfunction was observed after starting amiodarone. Subsequently, she underwent intra-aortic balloon pump insertion in addition to inotropic agent administration; however, venoarterial extracorporeal membrane oxygenation and Impella 5.0 were needed because biventricular dysfunction progressed. We diagnosed our patient with cardiac sarcoidosis based on the pathological findings revealing inflammatory cell infiltration, including giant cells with extensive fibrosis and granulomas. However, the possibility of giant cell myocarditis could not be ruled out because of the fulminant clinical course; therefore, aggressive immunosuppressive therapy with corticosteroids and cyclosporine was started. Her cardiac function improved, and all mechanical circulatory support and inotropic agents were discontinued. Conclusion: Cardiac sarcoidosis is difficult to differentiate from giant cell myocarditis because they have many similarities in terms of myocardial histopathology and clinical manifestations. While whether the two diagnoses are parts of a single-disease continuum remains debatable, aggressive combination immunosuppressive therapy may contribute to favourable outcomes.

High-risk and low prevalence disease: Cardiac sarcoidosis and some of its mimics

In this narrative review of cardiac sarcoidosis, based on a literature search using the terms "cardiac sarcoidosis", "tuberculous myocarditis", "Whipple's disease and myocarditis", and"idiopathic giant cell myocarditis", I have defined cardiac sarcoidosis as a disorder which can be diagnosed either by documentation of the presence of sarcoid-related granulomas in myocardial tissue or by documentation of the association of the presence of sarcoid-related granulomas in extracardiac tissue and symptoms such as complete heart block, ventricular tachyarrhythmia, sudden death or dilated cardiomyopathy which are typical of cardiac sarcoidosis. The differential diagnosis of cardiac sarcoidosis includes granulomatous myocarditis attributable to underlying causes such as such as tuberculosis, Whipple's disease, and idiopathic giant cell myocarditis. Diagnostic pathways for cardiac sarcoidosis include biopsy of cardiac and extracardiac tissue, nuclear magnetic resonance imaging, positron emission tomography, and a diagnostic trial of empiric therapy. Problem areas include differentiation between noncaseating granulomatosis attributable to sarcoidosis versus noncaseating granulomatosis attributable to tuberculosis and whether or not the workup of suspected cardiac sarcoidosis should always include evaluation of biopsy tissue by molecular methods for M tuberculosis DNA as well as by mycobacterium tuberculosis culture. The diagnostic significance of necrotising granulomatosis is also unclear. Evaluation of patients on long term immunotherapy should also take due account of the risk of tuberculosis attributable to the use of tumor necrosis factor-alpha antagonists.

Refractory Sarcoidosis: A Review

Sarcoidosis is a multi-system disease of unknown etiology characterized by granuloma formation in various organs (especially lung and mediastinohilar lymph nodes). In more than half of patients, the disease resolves spontaneously. When indicated, it usually responds to corticosteroids, the first-line treatment, but some patients may not respond or tolerate them. An absence of treatment response is rare and urges for verifying the absence of a diagnosis error, the good adherence of the treatment, the presence of active lesions susceptible to respond since fibrotic lesions are irreversible. That is when second-line treatments, immunosuppressants (methotrexate, leflunomide, azathioprine, mycophenolate mofetil, hydroxychloroquine), should be considered. Methotrexate is the only first-line immunosuppressant validated by a randomized controlled trial. Refractory sarcoidosis is not yet a well-defined condition, but it remains a real challenge for the physicians. Herein, we considered refractory sarcoidosis as a disease in which second-line treatments are not sufficient to achieve satisfying disease control or satisfying corticosteroids tapering. Tumor necrosis alpha inhibitors, third-line treatments, have been validated through randomized controlled trials. There are currently no guidelines or recommendations regarding refractory sarcoidosis. Moreover, criteria defining non-response to treatment need to be clearly specified. The delay to achieve response to organ involvement and drugs also should be defined. In the past ten years, the efficacy of several immunosuppressants beforehand used in other autoimmune or inflammatory diseases was reported in refractory cases series. Among them, anti-CD20 antibodies (rituximab), repository corticotrophin injection, and anti-JAK therapy anti-interleukin-6 receptor monoclonal antibody (tocilizumab) were the main reported. Unfortunately, no clinical trial is available to validate their use in the case of sarcoidosis. Currently, other immunosuppressants such as JAK inhibitors are on trial to assess their efficacy in sarcoidosis. In this review, we propose to summarize the state of the art regarding the use of immunosuppressants and their management in the case of refractory or multidrug-resistant sarcoidosis.