Like a House Afire: Cardiac Sarcoidosis James D. Richardson, MBBS, Michael S. Cunnington, MBBS, Adam J. Nelson, MBBS, Julie A. Bradley, PhD, Karen S.L. Teo, PhD, Stephen G. Worthley, PhD, Matthew I. Worthley, PhD The American Journal of Medicine Volume 126, Issue 1, Pages 21-24 (January 2013) DOI: 10.1016/j.amjmed.2012.09.002 Copyright © 2013 Elsevier Inc. Terms and Conditions
Figure 1 An electrocardiogram (ECG) obtained during the 24 hours following presentation demonstrated 1-mm ST-segment elevation in leads I and aVL with T-wave inversion in the inferolateral leads. The American Journal of Medicine 2013 126, 21-24DOI: (10.1016/j.amjmed.2012.09.002) Copyright © 2013 Elsevier Inc. Terms and Conditions
Figure 2 Cardiac magnetic resonance imaging was very useful. A, This transverse image showed mediastinal lymphadenopathy, marked here with an asterisk. B, A T2-weighted image had increased signal at the apex, indicating myocardial edema. C, An inversion recovery horizontal long-axis image exhibits late gadolinium enhancement in the septum and distal lateral walls. Note the differing localization of late enhancement to that of the edema shown in 2B—concomitant sarcoid involvement is reflected, but at different evolutionary stages. D, A short-axis image displays extensive late gadolinium enhancement of the distal anterior and inferior myocardium. Sparing of the subendocardium and the noncoronary distribution (anterior wall involved with proximal septum-sparing) suggest a noncoronary etiology. The American Journal of Medicine 2013 126, 21-24DOI: (10.1016/j.amjmed.2012.09.002) Copyright © 2013 Elsevier Inc. Terms and Conditions
Figure 3 A discrete well-formed granuloma composed of epithelioid histiocytes was evident after hematoxylin and eosin staining. The American Journal of Medicine 2013 126, 21-24DOI: (10.1016/j.amjmed.2012.09.002) Copyright © 2013 Elsevier Inc. Terms and Conditions
Figure 4 The patient's progress was examined with ECG and cardiac MRI. A, Almost 6 months after initial presentation, despite treatment with prednisolone, the patient's ECG showed new anterolateral T-wave inversion. B, A second cardiac MRI showed more extensive late gadolinium enhancement in the anteroseptum and apex—the same region where edema was identified on the first cardiac MRI. This demonstrates the pathological evolution of cardiac sarcoidosis. C, After the patient was placed on a more intensive immunotherapy regimen, an ECG demonstrated marked improvement with residual abnormalities in aVL only. D, Three months after beginning more powerful treatment, a third cardiac MRI demonstrated improvement in late gadolinium enhancement. The American Journal of Medicine 2013 126, 21-24DOI: (10.1016/j.amjmed.2012.09.002) Copyright © 2013 Elsevier Inc. Terms and Conditions