Cardiac sarcoid

Cardiac sarcoid workupToday we discussed a fantastic case with Izzy about a woman presenting with acute on chronic HF symptoms and chest tightness who is c/f a presentation of cardiac sarcoid!

Cardiac sarcoid: Cardiac sarcoid is a rare event occurring in 5% of patients with systemic sarcoid. Clinical manifestations include conduction abnormalities (BBB, AVB), tachyarrhythmia, cardiomyopathy, CHF, valvular dysfunction, and sudden cardiac death. Pericardial disease is rare. Cor pulmonale can occur with advanced lung disease.

Sarcoid can actually infiltrate the coronary arteries leading to spasm or vasculitis and can thus cause anginal symptoms!

The cardiac manifestations can precede, follow, or occur during involvement of the lungs or other organs.

Attached is a helpful algorithm for making the dx.

Utility of imaging in cardiac sarcoid:

Much of the discussion today was also about the imaging findings that may lead you to suspect a dx of cardiac sarcoid. Below are the findings based on various imaging modalities that may lead you to suspect cardiac sarcoid:

ECHO: 1st line imaging. LV dilatation, septal thinning, segmental or global hypokinesia of the LV or RV, aneurism formation, valvular regurgitation, simulated LV hypertrophy from infiltration into the myocardium.

Cardiac MRI: Technique of choice for the dx of cardiac sarcoid w/ the highest sensitivity and specificity. Late gadolinium enhancement (LGE) may have prognostic value in evaluating chronic sarcoid as you have scar formation and increased risk of death presumably from arrhythmia.

Cardiac PET: Excellent imaging modality for active sarcoid, but less specific as can have false positives with other inflammatory myocardial diseases.

Filed under: Morning Report

Periodic paralysis syndromes!

This past week in ICU report we talked about weakness in a patient with primarily proximal>distal LMN as well as bulbar findings who needed to be intubated for control of secretions. Right now he is being treated for GBS (Miller-Fisher variant) w/ IVIG, but given his history of Graves disease a large part of the discussion was on the periodic paralysis syndromes. So cool!

Attached is a table covering the 4 most common periodic paralysis syndromes. The pathophysiology is related to mutations in ion channels (typically potassium). Potassium levels can actually be high, low, or normal making the dx quite challenging.

Many of the syndromes are brought on by exercise, large carbohydrate meals, or fasting which is another clue on history.

#GoopPEARL: don’t replete the potassium in the hypokalemic periodic paralysis syndromes as it is related to short term K shifts, and one the paralysis resolves the K will normalize.

Filed under: Morning Report