Cardiovascular Journal of Africa: Vol 26 No 2 (March/April 2015)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 2, March/April 2015 96 AFRICA
Two cases of cardiac sarcoidosis in pregnant women
with supraventricular arrhythmia
Ebru Ertekin, Sulaiman Moosa, Jolien W Roos-Hesselink, Karen Sliwa
Abstract
We present two cases of cardiac sarcoidosis whose first pres-
entation was in pregnancy. All findings confirmed the diagno-
sis of sarcoidosis with cardiac involvement in both patients.
The first patient, a 37-year-old, presented with dizziness
and atrial fibrillation at 16 weeks’ gestation. Echocardiogra-
phy revealed thickened interventricular septum with a speck-
led pattern. Cardiac MRI after delivery showed myocardial
oedema/inflammation corresponding with the same regions
with early enhancement and epicardial delayed enhancement
in the basal to mid-inferoseptal and basal anterior left ventric-
ular myocardial segments. Transbronchial biopsy revealed
histology of scanty fragments of inflamed bronchial mucosa.
The second patient, a 31-year-old, was 17 weeks preg-
nant when she presented with daily palpitations and short-
ness of breath. She had prolonged episodes of supraven-
tricular tachycardia. Echocardiography revealed a speckled
septal and right ventricular wall pattern. Cardiac MRI after
delivery showed basal and mid-ventricular mesocardial and
epicardial enhancement, most compatible with sarcoidosis.
Keywords: cardiac sarcoidosis, pregnancy, arrhythmia
Submitted 2/10/14, accepted 3/2/15
Cardiovasc J Afr 2015; 26: 96–100
DOI: 10.5830/CVJA-2015-022
Case 1: patient with atrial fibrillation
A 37-year-old primigravida presented to our cardiac clinic
at 16 weeks’ gestation with a history of dizziness and atrial
fibrillation (AF) without overt heart disease. She took no regular
medication, did not smoke or drink alcohol, and had no diabetes
mellitus or hypertension. Her medical history included AF
diagnosed six years previously, and polycystic ovarian syndrome.
There was no cardiac disease or sudden death in her family.
Physical examination revealed an irregular tachycardia of
130 beats per minute (bpm), blood pressure of 124/72 mmHg
and no murmur. The electrocardiogram showed ventricular
ectopics, intermittent AF and irregular P-wave morphology (Fig.
1). Echocardiography revealed a normal heart with an ejection
fraction of 60%. She was prescribed atenolol 25 mg daily and
aspirin 75 mg daily due to the risk of a cerebrovascular accident.
Echocardiography was repeated one month later and showed
a thickened speckled septum and posterior wall with good left
ventricular function (left ventricular ejection fraction 61%, left
atrial diameter 34 mm, aortic diameter 28 mm, left ventricular
end-diastolic diameter 53 mm). These findings were suspicious
for an infiltrative disease, and cardiac sarcoidosis was considered
to be the most probable diagnosis. The obstetric–cardiac team
made a decision at that time to perform a full work-up for
cardiac sarcoidosis post delivery.
She delivered under spinal and general anaesthetia at 38
weeks of gestation by caesarean section due to breech position.
She gave birth to a healthy female baby of 2 780 g. On discharge
she was prescribed aspirin 80 mg, eltroxin 100 μg and atenolol
50 mg. Three months post partum she had mild to moderate
shortness of breath on effort, her blood pressure was 110/78
mmHg and her heart rate was 70–80 bpm while she was in AF.
MRI was performed four months after delivery and
demonstrated the following findings: preserved biventricular
systolic function and volumes, myocardial oedema or
inflammation corresponding to the same regions with early
enhancement and epicardial delayed enhancement in the basal to
mid-inferoseptal and basal anterior left ventricular myocardial
segments (Fig. 2). With these MRI findings, cardiac sarcoidosis
was considered to be the most probable diagnosis. However,
myocarditis was a less likely differential consideration.
CT chest demonstrated multiple bilateral pulmonary nodules
predominantly in a perilymphatic distribution. Transbronchial
biopsy confirmed the diagnosis of sarcoidosis. Microscopic
examination showed scanty fragments of inflamed bronchial
mucosa. Granulomas and viral inclusions were not seen.
Additionally, serum angiotensin converting enzyme level was
23.8 U/l (normal range: 9–67 U/l).
Steroid therapy was started after the diagnosis of sarcoidosis
by transbronchial biopsy. At the follow-up visit 10 months after
delivery, her symptoms had improved and she was on atenolol
25mgdaily,prednisone40mgdaily,withcalciumsupplementation,
vitamin D, isoniazid 200 mg daily (antibiotics) and eltroxin
100 mcg daily.
All findings confirmed the diagnosis of sarcoidosis. As there
was cardiac involvement, steroid therapy was prescribed. Steroid
therapy was successful and improved her symptoms.
Case 2: patient with supraventricular
tachycardia
The second patient we saw was a 31-year-old woman who was
17 weeks pregnant with her third pregnancy. She had prolonged
Department of Cardiology, Erasmus University Medical
Center, Rotterdam, The Netherlands
Ebru Ertekin, BSc
Jolien W Roos-Hesselink, MD, PhD
Department of Radiology, 2 Military Hospital, Cape Town,
South Africa
Sulaiman Moosa, MD
Hatter Institute for Cardiovascular Research in Africa,
MRC Inter Cape Heart Group, Department of Medicine,
University of Cape Town, South Africa
Karen Sliwa, MD, PhD,