CARDIOVASCULAR JOURNAL OF AFRICA • Vol 21, No 3, May/June 2010
158
AFRICA
Case Report
Reconciling Q waves and late gadolinium enhancement
with no angiographic evidence of coronary disease:
cardiac sarcoidosis presenting as decompensated
heart failure
RYAN P MORRISSEY, KIRAN J PHILIP, ERNST R SCHWARZ
Summary
Cardiac sarcoidosis is rare and subclinical involvement is
four to five times more common than clinical involvement.
Cardiac sarcoidosis is associated with a poor prognosis.
ECG abnormalities are the most common presentation.
However, as this case illustrates, it can also present as acute
decompensated heart failure. Screening with cardiac posi-
tron emission tomography (PET) or magnetic resonance
imaging (MRI) is highly suggested in patients with suspected
disease. Diagnosis allows for early initiation of corticoster-
oids. Cardiac sarcoidosis is more common than previously
thought. However, with treatment, survival may also be better
than previously reported.
Keywords:
cardiac sarcoidosis, cardiac MRI (CMR), restrictive
cardiomyopathy
Submitted 4/8/09; accepted 13/10/09
Cardiovasc J Afr
2010;
21
: 158–163
Sarcoidosis is a systemic granulomatous disease of unknown
aetiology presenting in young and middle-aged adults and is
almost three times more common in blacks than whites.
1,2
The
most common organ involved is the lung, but sarcoidosis can
also affect multiple organ systems including the heart.
1
Jonathan Hutchinson described the first case of cutaneous
sarcoid in 1869.
3
However, the illness was named by Cæsar Peter
Møller Boeck in 1899.
4
Bernstein
et al
. were the first to recog-
nise cardiac involvement in 1929.
5
Cardiac sarcoidosis most commonly manifests with abnormal
ECG findings, including atrial and ventricular arrhythmias and
varying degrees of atrio-ventricular block. Patients can present
with symptoms of pre-syncope secondary to conduction abnor-
malities or symptoms of heart failure due to left ventricular
dysfunction, mitral regurgitation or conduction abnormalities.
6,7
Mortality is increased in sarcoidosis patients with cardiac
involvement.
8
Outcome data regarding conventional treatment of arrhyth-
mias and heart failure in patients with cardiac sarcoidosis are
lacking. Corticosteroid treatment improves mortality,
9,10
and
heart transplant recipients do as well as patients transplanted for
other indications,
11
although recurrence rates of cardiac sarcoido-
sis are not known.
Sarcoidosis should be in the differential for hilar lymphad-
enopathy, particularly in patients of African descent. This case
illustrates that one should consider cardiac sarcoidosis and other
infiltrative diseases when ECG or cardiac imaging findings do
not reflect angiographic data.
Case report
A 50-year-old African-American male presented to the emer-
gency department with one week of shortness of breath at rest,
which had prevented him from going to work, and five months
of increasing dyspnoea on exertion. The patient denied any chest
pain, palpitations, lower extremity swelling or cough. He had
been experiencing night sweats for one week and endorsed a
10-lb (4.5-kg) weight loss over the previous five months. The
patient, who worked in a warehouse, had been diagnosed in the
past with reactive airway disease. He did not smoke but was
formerly a heavy drinker and denied any history of illicit drug
use. His family history was negative for heart and lung disease
as well as malignancies.
On physical examination, temperature was 99.4° F (37.4° C),
blood pressure was 115/68 mmHg, heart rate was 115 beats/
minute and regular, respiratory rate was 20 /minute, and oxygen
saturation was 94% on two litres oxygen via nasal cannula.
The patient was diaphoretic and respirations were augmented
with accessory muscle use. The heart was tachycardic but with
regular rhythm with occasional premature beats. S1 and S2 were
normal without murmurs, rubs or gallops. The point of maximal
impulse was not displaced. There was no jugular venous disten-
tion. Diffuse, coarse expiratory wheezes were present bilater-
ally without rales. Lower extremities were without oedema, and
pulses were 2
+
bilaterally. The digits of the hands exhibited
clubbing. There were numerous hypopigmented plaques of 1 to
2 cm located on the upper back.
An upright, two-view chest X-ray revealed bilateral upper
lobe infiltrates and diffuse interstitial markings (Fig. 1). An
Cedars Sinai Heart Institute, Cedars-Sinai Medical Center,
and David Geffen School of Medicine, University of
California Los Angeles (UCLA), California, USA
RYAN P MORRISSEY, MD
KIRAN J PHILIP, MD
ERNST R SCHWARZ, MD, PhD, FESC, FACC, FSCAI,
