Sarcoidosis and the heart: A review of the literature

Isolated cardiac sarcoidosis: A clinical challenge

Sarcoidosis is an inflammatory disease characterised by non-caseating granulomas of unclear aetiology. Isolated cardiac sarcoidosis (ICS) is rare and occurs when there is granulomatous infiltration of myocardial tissue without evidence of extracardiac sarcoidosis. The heterogeneity in clinical manifestations often presents a diagnostic challenge which leads to delays in treatment initiation. Our case highlights the often quiescent presentation of ICS, the importance of early treatment and the diagnostic challenges that contribute to its underdiagnosis.

Characteristics and Outcomes of Hospitalized Patients With Heart Failure and Sarcoidosis: A Propensity-Matched Analysis of the Nationwide Readmissions Database 2010-2019

BACKGROUND

Sarcoidosis is associated with a poor prognosis. There is a lack of data examining the outcomes and readmission rates of sarcoidosis patients with heart failure (SwHF) and without heart failure (SwoHF). We aimed to compare the impact of non-ischemic heart failure on outcomes and readmissions in these two groups.

METHODS

The US Nationwide Readmission Database was queried from 2010 to 2019 for SwHF and SwoHF patients identified using the International Classification of Diseases, 9th and 10th Editions. Those with ischemic heart disease were excluded, and both cohorts were propensity matched for age, gender, and Charlson Comorbidity Index (CCI). Clinical characteristics, length of stay, adjusted healthcare-associated costs, 90-day readmission and mortality were analyzed.

RESULTS

We identified 97,961 hospitalized patients (median age 63 years, 37.9% male) with a diagnosis of sarcoidosis (35.9% SwHF vs 64.1% SwoHF). On index admission, heart failure patients had higher prevalences of atrioventricular block (3.3% vs 1.4%, P < .0001), ventricular tachycardia (6.5% vs 1.3%, P < .0001), ventricular fibrillation (0.4% vs 0.1%, P < .0001) and atrial fibrillation (22.1% vs 7.5%, P < .0001). SwHF patients were more likely to be readmitted (hazard ratio 1.28, P < .0001), had higher length of hospital stay (5 vs 4 days, P < .0001), adjusted healthcare-associated costs ($9,667.0 vs $9,087.1, P < .0001) and mortality rates on readmission (5.1% vs 3.8%, P < .0001). Predictors of mortality included heart failure, increasing age, male sex, higher CCI, and liver disease.

CONCLUSION

SwHF is associated with higher rates of arrhythmia at index admission, as well as greater hospital cost, readmission and mortality rates compared to those without heart failure.

A rare case of pericardial sarcoidosis presenting as chest pain

Key Clinical Message

Pericardial sarcoidosis is an uncommon cause of chest pain to consider, and it requires a heightened level of suspicion and thorough history gathering. If there is suspicion of inflammatory disease, pursuing advanced imaging and biopsies is crucial, as early immunosuppressive treatment can enhance outcomes.

Abstract

Pericardial involvement in sarcoidosis is a rare condition with limited research. This case study discusses a 52-year-old African American woman who presented with subacute chest pain and was diagnosed with pericardial sarcoidosis. Diagnostic evaluation revealed extensive lymphadenopathy and pericardial effusion, and a pericardial biopsy confirmed non-caseating granulomatous inflammation. Treatment with steroids and methotrexate resulted in clinical improvement. Eight months follow-up showed near resolution of pericardial disease. This case emphasizes the importance of considering cardiac sarcoidosis in sarcoidosis patients, utilizing advanced imaging for accurate diagnosis, and tailoring treatment to the level of cardiac involvement.

Automatic Implantable Cardioverter Defibrillator (AICD) Implantation as Secondary Prevention of Cardiac Sarcoidosis-Associated Ventricular Tachycardia

BACKGROUND

Cardiac sarcoidosis can cause a wide range of symptoms, including shortness of breath, chest pain, oedema, and fatal arrhythmias such as ventricular tachycardia (VT). Because the symptoms can be nonspecific, diagnosing cardiac sarcoidosis can be challenging. Treatment options may include corticosteroids to reduce inflammation, immunosuppressive drugs to prevent further damage, medications to control symptoms, ablation procedures, and defibrillators to prevent cardiac arrest.

CASE

A 60-year-old woman who has sarcoidosis affecting multiple organs including cardiac sarcoidosis, non-ischemic cardiomyopathy with reduced ejection fraction, and hypertension, was admitted with tachycardia, shortness of breath, and a recently fired automatic implantable cardioverter defibrillator (AICD). Three months prior, the patient was admitted for a syncopal episode and diagnosed with cardiac sarcoidosis through cardiac magnetic resonance imaging (MRI) and positron emission tomography (PET), which demonstrated active inflammation, and an AICD was implanted. During this admission, the patient had an episode of ventricular tachycardia and was treated with amiodarone and lidocaine. The patient received steroids, sacubitril/valsartan, and methotrexate. After 48 hours of observation, the patient was discharged without further events.

CONCLUSION

Cardiac sarcoidosis is a rare but serious disease that can lead to life-threatening cardiac complications such as ventricular tachycardia. Early diagnosis and aggressive management are crucial for improving outcomes and preventing sudden cardiac death. AICD implantation as a secondary prevention in cardiac sarcoidosis might prevent cardiac arrest."

LEARNING POINTS

Cardiac sarcoidosis can present with non-specific symptoms and lead to life-threatening arrhythmias such as ventricular tachycardia, emphasising the importance of early diagnosis and aggressive management to prevent sudden cardiac death.A multidisciplinary approach involving imaging modalities such as cardiac magnetic resonance imaging (MRI) and positron emission tomography (PET) scans, along with histological findings, is crucial for accurately diagnosing cardiac sarcoidosis, as endomyocardial biopsy alone has low sensitivity.Implantation of an automatic implantable cardioverter defibrillator (AICD) as a secondary prevention measure should be considered in cardiac sarcoidosis patients, even in elderly individuals with mildly to moderately reduced ejection fraction, to prevent fatal arrhythmias and sudden cardiac death.

The role of the host-microbiome and metabolomics in sarcoidosis

Sarcoidosis is a complex inflammatory fibrotic disease that affects multiple organ systems. It is characterized by the infiltration of lymphocytes and mononuclear phagocytes, which form non-caseating granulomas in affected organs. The lungs and intrathoracic lymph nodes are the most commonly affected organs. The underlying cause of sarcoidosis is unknown, but it is believed to occur in genetically predisposed individuals who are exposed to pathogenic organisms, environmental contaminants, or self and non-self-antigens. Recent research has suggested that the microbiome may play a role in the development of respiratory conditions, including sarcoidosis. Additionally, metabolomic studies have identified potential biomarkers for monitoring sarcoidosis progression. This review will focus on recent microbiome and metabolomic findings in sarcoidosis, with the goal of shedding light on the pathogenesis and possible diagnostic and therapeutic approaches.

Cardiac sarcoidosis: a comprehensive review of risk factors, pathogenesis, diagnosis, clinical manifestations, and treatment strategies

Cardiac Sarcoidosis (CS) is a deadly consequence of systemic sarcoidosis that inflames all three layers of the heart, especially the myocardium-clinical signs of CS range from asymptomatic disease to abrupt cardiac death. CS generally remains undiagnosed secondary to a lack of definitive diagnostic criteria, a high percentage of false negative results on endomyocardial biopsy, and ill-defining clinical manifestations of the disease. Consequently, there is a lack of evidence-based recommendations for CS, and the present diagnostic and therapeutic management depend on expert opinion. The aetiology, risk factors, clinical symptoms, diagnosis, and therapy of CS will be covered in this review. A particular emphasis will be placed on enhanced cardiovascular imaging and early identification of CS. We review the emerging evidence regarding the use of Electrocardiograms (ECGs), Magnetic Resonance Imaging (MRI), and Positron Emission Tomography (PET) imaging of the heart to identify and quantify the extent of myocardial inflammation, as well as to guide the use of immunotherapy and other treatment regimens, such as ablation therapy, device therapy, and heart transplantation, to improve patient outcomes.

Cardiac Sarcoidosis: A Unique Presentation

Isolated cardiac sarcoidosis is a rare subset of sarcoidosis, a systemic autoimmune condition primarily found in African American females. The manifestations of cardiac sarcoidosis include atrioventricular and bundle branch blocks, arrhythmias, heart failure, and pericardial effusions, although these complications occur at varying prevalence. The diagnosis of cardiac sarcoidosis requires several different criteria; however, recent literature has focused heavily on imaging modalities such as cardiac magnetic resonance imaging. We present a case of a 42-year-old Caucasian male who was found to have unexplained cardiac arrhythmias and ultimately diagnosed with cardiac sarcoidosis by imaging modalities.

Advanced Echocardiography Techniques: The Future Stethoscope of Systemic Diseases

Cardiovascular disease (CVD) has been showing patterns of extensive rise in prevalence in the contemporary era, affecting the quality of life of millions of people and leading the causes of death worldwide. It has been a provocative challenge for modern medicine to diagnose CVD in its crib, owing to its etiological factors being attributed to a large array of systemic diseases, as well as its non-binary hideous nature that gradually leads to functional disability. Novel echocardiography techniques have enabled the cardiac ultrasound to provide a comprehensive analysis of the heart in an objective, feasible, time- and cost-effective manner. Speckle tracking echocardiography, contrast echocardiography, and 3D echocardiography have shown the highest potential for widespread use. The uses of novel modalities have been elaborately demonstrated in this study as a proof of concept that echocardiography has a place in routine general practice with supportive evidence being as recent as its role in the concurrent COVID-19 pandemic. Despite such evidence, many uses remain off-label and unexploited in practice. Generalization of echocardiography at the point of care can become a much-needed turning point in the clinical approach to case management. To actualize such aspirations, we recommend further prospective and interventional studies to examine the effect of implementing advanced techniques at the point of care on the decision-making process and evaluate their effectiveness in prevention of cardiovascular morbidities and mortalities.

Inpatient Characteristics, Complications, and Outcomes of Patients with Cardiac Sarcoidosis: A Study from The National Inpatient Sample

Although seen in ∼5% of sarcoidosis patients, cardiac sarcoidosis (CS) accounts for nearly 25% of disease-related deaths. This study aimed to describe characteristics and outcomes among CS patients. Patients diagnosed with CS in 2016-2017 in the US National Inpatient Sample Database were evaluated to study patient characteristics, reasons ascribed to admission, in-hospital outcomes, and complications. A total of 2420 patients (median age 56 years) were included in the analysis. Most admissions occurred due to ventricular tachycardia (12.8%), followed by myocarditis (9.9%) with a mean length of stay of 7±7 days. The overall incidence of in-hospital mortality was 2.5%.

Heart transplantation outcomes in cardiac sarcoidosis

BACKGROUND

Cardiac sarcoidosis (CS) is a progressive inflammatory cardiomyopathy that can lead to heart failure, arrhythmia, and death. There is limited data on Orthotopic Heart Transplantation (OHT) outcomes in patients with CS. Here we examine outcomes in patients with CS who have undergone OHT at centers throughout the United States from 1987 to 2019.

METHODS

This was an analysis of 63,947 adult patients undergoing OHT captured in the United Network for Organ Sharing (UNOS) registry. Patients were characterized as cardiac sarcoidosis (CS) or Non-CS. Baseline characteristics were compared using chi-square and Kruskal-Wallis Tests. Outcomes of interest included primary graft failure, patient survival, treated graft rejection, hospitalization for infection, and post-transplant malignancy.

RESULTS

During the study period 227 patients with CS underwent OHT. Patients with CS were younger, had higher proportion of non-white patients, and received transplants at more urgent statuses. After multivariable modeling there was no difference in survival (HR 0.86, CI 0.59-1.3, p = 0.446) or graft failure (HR 0.849, CI 0.58-1.23, p = 0.394) between patients with CS and Non-CS. Patients with CS had lower odds of rejection (OR 0.558, CI 0.315- 0.985, p = 0.0444). Patients with CS had similar odds of hospitalization for infection and post-transplant malignancy, as Non-CS patients.

CONCLUSIONS

Patients with CS and Non-CS had similar post OHT survival, odds of graft failure, hospitalizations for infection, and post-transplant malignancy. Results of this study confirm the role of heart transplantation as a viable option for patients with CS.

Cardiac Sarcoidosis: A Clinical Overview

Cardiac sarcoidosis (CS) with clinical manifestation occurs in about 5-8% of patients with sarcoidosis. CS may be clinically suspected by the presence of ventricular arrhythmia, conduction abnormalities, and heart failure (HF). However, 20%-25% of patients may present with silent CS, having asymptomatic cardiac involvement. The diagnosis of CS is based on findings from nuclear studies, cardiac magnetic resonance, and extra-cardiac tissue biopsy. Due to the inflammatory nature of the disease, immunosuppressive medications are a cornerstone of therapy. The treatment also includes recommended HF medical therapies. Since CS patients are at risk of sudden cardiac death resulting from progression of cardiac dysfunction or the presence of scar originating from fatal arrhythmias, implantable cardioverter-defibrillators should be considered, with special indication beyond accepted recommendations in HF. In CS, the extent of left ventricular dysfunction is the most important mortality predictor. Heart transplant or mechanical circulatory support may represent life saving strategies in selective CS patients.

Cardiac Sarcoidosis: Pathophysiology, Diagnosis, and Management

Sarcoidosis is a chronic multi-system disorder with an unknown etiology that can affect the cardiac tissue, resulting in Cardiac Sarcoidosis (CS). The majority of these CS cases are clinically silent, and when there are symptoms, the symptoms are vague and can have a lot in common with other common cardiac diseases. These symptoms can range from arrhythmias to heart failure. If CS goes undetected, it can lead to detrimental outcomes for patients. Diagnosis depends on timely utilization of imaging modalities and non-invasive testing, while in some cases, it does necessitate biopsy. Early diagnosis and treatment with immunosuppressive agents are crucial, and it is essential that follow-up testing be performed to ensure resolution and remission. This manuscript provides an in-depth review of CS and the current literature regarding CS diagnosis and treatment.

Detection of cardiac involvement in pulmonary sarcoidosis using high-resolution Holter electrocardiogram

BACKGROUND

Early detection of cardiac involvement in patients with sarcoidosis is important but currently unresolved. The aim of this study was to elucidate the utility of frequency domain microvolt T-wave alternans (TWA), signal-averaged ECG (SAECG), and heart rate turbulence (HRT) using 24-hour Holter ECG for detecting cardiac involvement in patients with pulmonary sarcoidosis.

METHODS

This study consisted of consecutive 40 pulmonary sarcoidosis patients (11 males, 62 ± 13 years) who underwent 24-hour Holter monitoring with and without cardiac involvement. All patients underwent frequency domain TWA, SAECG, and HRT using 24-hour Holter monitoring. Patients with atrial fibrillation pacing or wide QRS electrocardiogram were excluded.

RESULTS

After 14 patients were excluded, a total of 26 patients (six males, 59 ± 14 years) were evaluated. Seven patients had cardiac involvement (cardiac sarcoidosis [CS] group). On the Holter SAECG, duration of low-amplitude signals <40 μV in the terminal filtered QRS complex (LAS40) was significantly higher, and root mean square voltage of the terminal 40 ms of the filtered QRS complex (RMS40) was significantly lower in the CS group compared with the non-CS group (LAS40: 61.4 ± 35.9 vs 37.6 ± 9.2 ms; P = .018, RMS40: 11.4 ± 10.3 vs 23.6 ± 13.2 ms; P = .023). Prevalence of positive late potential (LP) was also significantly higher in the CS group than that in the non-CS group (85.7% vs 31.5%; P = .026). The sensitivity, specificity, positive, and negative predictive values of LP for identifying patients with cardiac involvement were 85.7%, 68.4%, 50.0%, and 92.8%, respectively.

CONCLUSION

Holter SAECG may be useful for detecting cardiac involvement in patients with pulmonary sarcoidosis.

Dilated Cardiomyopathy Compatible With Sarcoidosis Presenting with Syncope Due to Torsades de Pointes: a Case Report

Sarcoidosis is a multisystemic noncaseating granulomatous disease of unknown etiology. Cardiac sarcoidosis clinical presentation is diverse, and syncope is one of the possible primary events. Due to its variable natural history and initial presentation associated with lacking sensitive and specific diagnostic tests, it still represents a challenging diagnosis. This article presents the case of a 51-year-old female patient with intermittent syncope events associated with torsades de pointes and dilated cardiomyopathy compatible with sarcoidosis.

Non-18F-FDG/18F-NaF Radiotracers Proposed for the Diagnosis and Management of Diseases of the Heart and Vasculature

¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) and ¹⁸F-sodium fluoride (¹⁸F-NaF) are front-runners in PET. However, these tracers have limitations in the imaging of diseases in the heart. A multitude of other radiotracers have been identified as potentially useful PET agents in the identification of cardiovascular disease. This critical review examines recent studies with the use of non-¹⁸F-FDG/¹⁸F-NaF radiotracers in the identification and surveillance of cardiovascular diseases. We highlight the need for further investigation into alternative PET radiotracers to demonstrate their clinical value in the management of these pathologies.

Sarcoidosis, the master mimicker

Sarcoidosis is an idiopathic multisystem disorder characterized by noncaseating granulomas. The article focuses on the typical imaging manifestations of sarcoid and the common differentials that need to be included when appropriate. Mistaking a sarcoid-mimicking disease for sarcoid can result in increased patient morbidity and mortality. The pulmonary system is the most common system involved and is typically the best understood by the radiologist, however a deeper knowledge of the pulmonary findings and features of sarcoid in other organ systems is critical. There is a myriad of sarcoid imaging manifestations that can involve every organ system. Often a confidant diagnosis of sarcoid can be made, however a broad differential may need to be considered- differential diagnoses include primary neoplasm, metastatic disease, infectious, and inflammatory etiologies. Radiologist familiarity with the multimodality multisystem imaging findings of sarcoid can help guide clinical management and optimize patient care.

The Multi-modality Cardiac Imaging Approach to Cardiac Sarcoidosis

BACKGROUND

Sarcoidosis is a multisystem granulomatous disease with a neglected but high prevalence of life-threatening cardiac involvement.

DISCUSSION

The clinical presentation of Cardiac Sarcoidosis (CS) depends upon the location and extent of the granulomatous inflammation, with left ventricular free wall the most common location followed by interventricular septum. The lack of a diagnostic gold standard and the unpredictable risk of sudden cardiac death pose serious challenges for the validation of accurate and effective screening test and the management of the disease. In the last few years advanced cardiac imaging modalities such as Cardiac Magnetic Resonance (CMR) and Positron Emission Tomography (PET) have significantly improved our knowledge and understanding of CS, and have also contributed in risk stratification, assessment of inflammatory activity and therapeutic monitoring of the disease.

CONCLUSION

In this review, we will discuss the state of the art in the diagnosis of CS focusing on the role and importance of multi-modality cardiac imaging.

Detection of arrhythmogenic substrate within QRS complex in patients with cardiac sarcoidosis using wavelet-transformed ECG

Signal-averaged electrocardiography (SAECG) has been known to be useful for prediction of lethal ventricular arrhythmias (VA). However, this technique has limitations in patients with intraventricular conduction disturbance (IVCD), which is common in cardiac sarcoidosis (CS). Meanwhile, wavelet-transformed ECG (WTECG) has been reported to be useful for detecting arrhythmogenic substrate hidden within QRS complex. The objective of this study was to assess the utility of WTECG for detecting arrhythmogenic substrate in patients with CS. Forty-four CS patients including 18 patients with VA were retrospectively investigated. The parameters on the signal-averaged electrocardiography (SAECG) and the power of frequency components on WTECG were compared between VA group and non-VA group. Eighteen patients have VA (VT: n = 17, VF: n = 1). LP were detected in 17 in VA group and 24 in non-VA group. WTECG showed that high-frequency components (HFC; 80-150 Hz) were developed in VA group. Peak power value at 150 Hz (P150) was significantly higher in VA group than that in non-VA group (442.9 ± 160.2 vs 316.7 ± 100.8, p = 0.006). The receiver operating characteristic (ROC) curve analysis showed an optimal cutoff point of 336 of P150 for detecting patients with VA, with 82.4% sensitivity, 61.5% specificity, and area under the curve of 0.74 (95% confidence interval [CI] 0.59-0.89). WTECG may be useful for detecting CS patients who are prone to VA.

miRNAs as Biomarkers in Disease: Latest Findings Regarding Their Role in Diagnosis and Prognosis

MicroRNAs (miRNAs) represent a class of small, non-coding RNAs with the main roles of regulating mRNA through its degradation and adjusting protein levels. In recent years, extraordinary progress has been made in terms of identifying the origin and exact functions of miRNA, focusing on their potential use in both the research and the clinical field. This review aims at improving the current understanding of these molecules and their applicability in the medical field. A thorough analysis of the literature consulting resources available in online databases such as NCBI, PubMed, Medline, ScienceDirect, and UpToDate was performed. There is promising evidence that in spite of the lack of standardized protocols regarding the use of miRNAs in current clinical practice, they constitute a reliable tool for future use. These molecules meet most of the required criteria for being an ideal biomarker, such as accessibility, high specificity, and sensitivity. Despite present limitations, miRNAs as biomarkers for various conditions remain an impressive research field. As current techniques evolve, we anticipate that miRNAs will become a routine approach in the development of personalized patient profiles, thus permitting more specific therapeutic interventions.

Diagnostic and predictive value of speckle tracking echocardiography in cardiac sarcoidosis

Background

Sarcoidosis is a systemic granulomatous disease that may affect the myocardium. This study evaluated the diagnostic and prognostic value of 2-dimensional speckle tracking echocardiography in cardiac sarcoidosis (CS).

Methods

Eighty-three patients with extracardiac, biopsy-proven sarcoidosis and definite/probable diagnosis of cardiac involvement diagnosed from January 2005 through December 2016 were included. Strain parameters in early stages of CS, in a subgroup of 23 CS patients with left ventricular ejection fraction (LVEF) within normal limits (LVEF> 52% for men: > 54% for women, mean value: 57.3% ± 3.8%) and no wall motion abnormalities was compared with 97 controls (1:4) without cardiac disease. LV and right ventricular (RV) global longitudinal (GLS), circumferential (GCS), and radial (GRS) strain and strain rate (SR) analyses were performed with TomTec software and correlated with cardiac outcomes (including heart failure and arrhythmias). This study was approved by the Mayo Clinic Institutional Review Board, and all patients gave informed written consent to participate.

Results

Mean age of CS patients was 53.6 ± 10.8 years, and 34.9% were women. Mean LVEF was 43.2% ± 12.4%; LV GLS, − 12.4% ± 3.7%; LV GCS, − 17.1% ± 6.5%; LV GRS, 29.3% ± 12.8%; and RV wall GLS, 14.6% ± 6.3%. In the 23 patients with early stage CS with normal LVEF and RV systolic function, strain parameters were significantly reduced when compared with controls (respectively: LV GLS, − 15.9% ± 2.5% vs − 18.2% ± 2.7% [P = .001]; RV GLS, − 16.9% ± 4.5% vs − 24.1% ± 4.0% [P < .001]). A LV GLS value of − 16.3% provided 82.2% sensitivity and 81.2% specificity for the diagnosis of CS (AUC 0.91), while a RV value of − 19.9% provided 88.1% sensitivity and 86.7% specificity (AUC 0.93). Hospital admission and heart failure significantly correlated to impaired LV GLS (> − 14%).

Conclusion

Reduced strain values in the LV GLS and RV GLS can be used in the diagnostic algorithm in patients with suspicion of cardiac sarcoidosis. These values also correlate with adverse cardiovascular events.

Extrapulmonary Involvement in Sarcoidosis: A Case Report

Sarcoidosis is an idiopathic multisystem granulomatous disease that affects patients of all races and ethnic groups however predilection for women and African Americans is apparent. Extrapulmonary manifestations of sarcoidosis occur in up to 50% of cases. The most common sites of extrapulmonary involvement are the skin, eyes, liver, and reticuloendothelial system followed bt renal, cardiac, and neurological involvement. We present the case of a middle age man with exclusive extrapulmonary sarcoidosis affecting the renal, cardiac, hepatic, splenic and central nervous system. The patient sustained a second episode of venous thromboembolism which highlights a frequently seen complication of sarcoidosis. We discuss the proposed pathophysiology for the prothrombotic state seen in sarcoidosis and imaging modalities that can be utilized to assess extrapulmonary involvement in sarcoidosis. Lastly, sarcoidosis management is reviewed, highlighting that immunosuppressants and tumor necrosis factor inhibitors are being proposed to arrest disease progression and reduce glucocorticoid doses.

Consecutive episodes of heart and kidney failure in an "otherwise" healthy young man

BACKGROUND

Acute renal failure is a rare occurrence in a patient with an unremarkable past medical history and should always lead to an in depth clinical study. The occurrence in the same healthy young subject, of consecutive episodes of heart failure and of acute renal failure is an even rarer event and should prompt diagnostic tests and restrict the diagnostic hypotheses.

CASE PRESENTATION

We present the case of a 28 year-old man who, while waiting to undergo assessment for a mild chronic kidney disease, was diagnosed with decompensated dilated cardiomyopathy and placed on diuretics and β-blockers. After few weeks he developed a non oligoanuric acute renal failure with a slight elevation of serum calcium. Renal biopsy proved suggestive for renal sarcoidosis; thus the hypothesis of systemic sarcoidosis with cardiac and renal involvement was possible avoiding further delay in initiation of therapy.

CONCLUSIONS

Cardiac sarcoidosis is usually silent but the majority of cases are diagnosed when cardiac symptoms are present in a patient with systemic sarcoidosis. Renal involvement with granulomatous interstitial nephritis is also quite rare and can be an unexpected finding at kidney biopsy. This case highlights the need to evaluate thoroughly clinical problems that do not fit in a specific scenario and emphasizes the importance of performing a kidney biopsy in case of kidney failure of unknown etiology.

[Diagnosis of isolated cardiac sarcoidosis]

Heart involvement in sarcoidosis is diagnosed in vivo in 5-7%, at autopsy in 25% of cases as a manifestation of a systemic process and an isolated one. Difficulties in the diagnosis of isolated sarcoidosis are due to the absence of known causes of the disease and to the lack of specificity of clinical manifestations. The main symptoms include cardiac conduction and rhythm disturbances, cardiomyopathy with the development of heart failure, as well as pericardial involvement. Routine techniques (ECG, EchoCG, daily ECG monitoring) and imaging of the structures of the heart and its function evaluation (MRI, PET, and scintigraphy) are used in diagnosis. A set of clinical, instrumental, and histological data obtained at endomyocardial biopsy may suggest isolated cardiac sarcoidosis with the exception of other diseases.

Magnetic resonance imaging of the heart in the diagnosis of sarcoidosis

Heart sarcoidosis diagnosis presents great difficulties due to the absence of specific clinical manifestations. Most often, the diagnosis is established during autopsy. Magnetic resonance imaging (MRI) of the heart with contrast enhancement is one of the most informative methods of intravital diagnosis of cardiac sarcoidosis. In this article, two clinical cases, shows the role of MRI of the heart with contrast enhancement in the diagnosis of cardiac sarcoidosis.

Cardiac sarcoidosis and ventricular arrhythmias. A rare association of a rare disease. A retrospective cohort study from the National Inpatient Sample and current evidence for management

BACKGROUND

Sarcoidosis is an increasingly recognized multi-systemic condition. Cardiac sarcoidosis is associated with ventricular arrhythmias and higher mortality rates. Little epidemiological data is available regarding the disease and associated ventricular arrhythmias.

METHODS

Data from the National Inpatient Sample (NIS) database 2012-2014, were reviewed. Dis-charges associated with sarcoidosis were identified as the target population using relevant ICD-9-CM codes. Primary outcome was a diagnosis of ventricular tachycardia (VT) in the sarcoidosis population. Secondary outcomes include rate of ventricular fibrillation (VF) and cardiac arrest. Subgroup analyses were performed to examine the association of VT with multiple potential confounding clinical variables.

RESULTS

Of 18,013,878 health encounters, 46,289 (0.26%) subjects had a diagnosis of sarcoidosis. VT and VF were more prevalent among patients with sarcoidosis compared to those without a diagnosis of sarcoidosis (2.29% vs. 1.22%; p < 0.001 and 0.25% vs. 0.21%; p < 0.001, respectively). Sarcoidosis was also associated with a higher prevalence of cardiac arrest (0.72% vs. 0.6%; p < 0.001). In unadjusted analyses, all examined comorbidities were significantly more common in those with sar-coidosis, including diabetes mellitus (31.6% vs. 21.25%; p < 0.001), hypertension (65.2% vs. 51.74%; p < 0.001), chronic kidney disease (21.09% vs. 14.02%; p < 0.001), heart failure (24.87% vs. 15%; p < 0.001) and acute coronary syndrome (4.32% vs. 3.35%; p < 0.001).

CONCLUSIONS

The present study showed that sarcoidosis was associated with increased rates of ven-tricular tachyarrhythmia, which can affect the overall disease morbidity and mortality.

Clinics in diagnostic imaging (189). Acute phase cardiac sarcoidosis (CS)

A 44-year-old man presented with breathlessness and episodes of palpitations for the last one year. The imaging diagnosis of cardiac sarcoidosis was made based on chest radiography and cardiac magnetic resonance (MR) imaging findings, and was further confirmed by biopsy. Cardiac sarcoidosis is an uncommon entity, yet is potentially fatal with nonspecific clinical manifestations, including sudden cardiac death. Hence, it is important to diagnose and treat this entity at an early stage to improve morbidity and mortality. Cardiac MR imaging plays a pivotal role in facilitating diagnosis and monitoring therapeutic response. We describe the MR imaging features of cardiac sarcoidosis and discuss imaging features of other cardiomyopathies that may mimic cardiac sarcoidosis.

Sarcoidosis from Head to Toe: What the Radiologist Needs to Know

Sarcoidosis is a multisystem granulomatous disorder characterized by development of noncaseating granulomas in various organs. Although the etiology of this condition is unclear, environmental and genetic factors may be substantial in its pathogenesis. Clinical features are often nonspecific, and imaging is essential to diagnosis. Abnormalities may be seen on chest radiographs in more than 90% of patients with thoracic sarcoidosis. Symmetric hilar and mediastinal adenopathy and pulmonary micronodules in a perilymphatic distribution are characteristic features of sarcoidosis. Irreversible pulmonary fibrosis may be seen in 25% of patients with the disease. Although sarcoidosis commonly involves the lungs, it can affect virtually any organ in the body. Computed tomography (CT), magnetic resonance imaging, and positron emission tomography/CT are useful in the diagnosis of extrapulmonary sarcoidosis, but imaging features may overlap with those of other conditions. Familiarity with the spectrum of multimodality imaging findings of sarcoidosis can help to suggest the diagnosis and guide appropriate management. ©RSNA, 2018.

Cardiac magnetic resonance imaging-indeterminate/negative cardiac sarcoidosis revealed by 18F-fluorodeoxyglucose-positron emission tomography: two case reports and a review of the literature

Background

Sarcoidosis is an inflammatory disorder of immune dysregulation characterized by non-caseating granulomas that can affect any organ. Cardiac sarcoidosis is an under-recognized entity that has a heterogeneous presentation and may occur independently or with any severity of systemic disease. Diagnosing cardiac sarcoidosis remains problematic with endomyocardial biopsies associated with a high risk of complications. Several diagnostic algorithms are currently available that rely on histopathology or clinical and radiological measures. The dominant mode of diagnostic imaging to date for cardiac sarcoidosis has been cardiac magnetic resonance imaging with gadolinium enhancement.

Case presentations

We report the cases of two adult patients: case 1, a 50-year-old white man who presented with severe congestive cardiac failure; and case 2, a 37-year-old white woman who presented with complete heart block. Both patients had a background of untreated pulmonary sarcoidosis. Cardiac magnetic resonance imaging did not show evidence of sarcoidosis in either patient and both proceeded to ¹⁸F-fluorodeoxyglucose-positron emission tomography scans that were highly suggestive of cardiac sarcoidosis. Both patients were systemically immunosuppressed with orally administered prednisone and methotrexate and had subsequent improvement by clinical and nuclear medicine imaging measures.

Conclusions

Current consensus guidelines recommend all patients with sarcoidosis undergo screening for occult cardiac disease, with thorough history and examination, electrocardiogram, and transthoracic echocardiogram. If any abnormalities are detected, advanced cardiac imaging should follow. While cardiac magnetic resonance imaging identifies the majority of cardiac sarcoidosis, early disease may not be detected. These cases demonstrate ¹⁸F-fluorodeoxyglucose-positron emission tomography is warranted following an indeterminate or normal cardiac magnetic resonance imaging if clinical suspicion remains high. Unidentified and untreated cardiac sarcoidosis risks significant morbidity and mortality, but early detection can facilitate disease-modifying immunosuppression and cardiac-specific interventions.

Individual nursing care for the elderly among China's aging population

By the end of 2014, China had an elderly population age 60 or over totaling 212 million; this group accounted for 15.5% of the country's total population of 1.37 billion, which means that China has passed the threshold for an aging population. As China's population ages and the disease spectrum changes, nursing services for the elderly must be expanded. Given differences in the health status, financial situation, and family composition of each elderly person, modern society is tending towards individual nursing care for the elderly. Adapting to the changing composition of society by age will present new challenges.

Sudden cardiac death and sarcoidosis of the heart in a young patient

Sarcoidosis is a granulomatous disease of unknown etiology affecting any organ, microscopically characterized by noncaseating granulomata. Cardiac involvement in sarcoidosis has been reported. It might be symptomatic or not and even revealed by sudden death. Heart conduction system is rarely investigated at autopsy, even in cases of sudden cardiac death. We present a case of a 32-year-old woman who died suddenly. The examination of the heart conduction system revealed a cardiac sarcoidosis that could explain the sudden death. The review of clinical data of the patient revealed some symptoms consistent/in agreement with this hypothesis. Cardiac sarcoidosis remains a diagnostic challenge and can be easily missed, clinically and pathologically. The retrospective analysis of clinical data and autopsy results of fatal and unusual cases might help to better understand sarcoidosis and its clinical presentations. Examination of the cardiac conduction system is crucial in selected cases of sudden cardiac death.

Occult etiologies of complete atrioventricular block: Report of two cases

In patients presenting with complete atrioventricular (AV) block, the common causes are degeneration of the conduction system, acute myocardial infarction, congenital and metabolic disorders (such as azotemia). However, at times, no cause can be ascribed and the label congenital or degenerative is applied depending on the patient's age and the QRS complex width. We present two cases of patients with complete AV block, who were subsequently found to have rare etiologies – sarcoidosis (with isolated feature of AV block) and non-Hodgkin's lymphoma.

Diurnal characteristics of heart rate variability in patients with sarcoidosis

BACKGROUND

The aim of this study was to evaluate autonomic nervous system function by measuring heart rate variability (HRV) in patients with sarcoidosis without known cardiac manifestations.

PATIENTS AND METHODS

The study comprised 61 participants, including 31 patients with sarcoidosis without known cardiac manifestations and 30 healthy volunteers. All participants underwent echocardiographic examination, 12-channel electrocardiography (ECG), and 24-h Holter monitoring. HRV parameters were determined and compared between the groups.

RESULTS

There were no differences between groups with regard to age, body mass index, systolic and diastolic blood pressure, or heart rate at the time of admission. In the time domain analyses, the 24-h, daytime, and night-time standard deviations of all normal-to-normal R‑R interval (SDNN) values were significantly lower in patients with sarcoidosis than those in the controls. The frequency domain analyses showed that 24-h and daytime low-frequency (LF) values, 24-h, daytime, and night-time high-frequency (HF) values were significantly lower in the patient group compared with the control group, whereas the night-time LF/HF ratio was significantly higher.

CONCLUSION

Although Holter ECG is not a diagnostic tool for cardiac sarcoidosis, the HRV parameters, especially the night-time LF/HF values, may demonstrate increased sympathetic activation in patients with sarcoidosis.