Sarcoidosis of the aortic root

The Clinical Features of Sarcoidosis: A Comprehensive Review

Sarcoidosis has innumerable clinical manifestations, as the disease may affect every body organ. Furthermore, the severity of sarcoidosis involvement may range from an asymptomatic state to a life-threatening condition. This manuscript reviews a wide variety of common and less common clinical characteristics of sarcoidosis. These manifestations are presented organ by organ, although additional sections describe systemic and multiorgan presentations of sarcoidosis. The lung is the organ most commonly involved with sarcoidosis with at least 90 % of sarcoidosis patients demonstrating lung involvement in most series. The skin, eye, liver, and peripheral lymph node are the next most commonly clinically involved organs in most series, with the frequency of involvement ranging from 10 to 30 %. The actual frequency of sarcoidosis organ involvement is probably much higher as it is frequently asymptomatic and may avoid detection. This is particularly common with lung, liver, cardiac, and bone involvement. Cardiac sarcoidosis is present in 25 % of all sarcoidosis but only causes clinical problems in 5 % of them. Nevertheless, unlike sarcoidosis involvement of most other organs, it may be suddenly fatal. Therefore, it is important to screen for cardiac sarcoidosis in all sarcoidosis patients. All sarcoidosis patients should also be screened for eye involvement as asymptomatic patients may have eye involvement that may cause permanent vision impairment. Pulmonary fibrosis from sarcoidosis is usually slowly progressive but may be life-threatening because of the development of respiratory failure, pulmonary hypertension, or hemoptysis related to a mycetoma or bronchiectasis. Some manifestations of sarcoidosis are not organ-specific and probably are the result of a release of mediators from the sarcoid granuloma. Two such manifestations include small fiber neuropathy and fatigue syndromes, and they are observed in a large percentage of patients.

Cardiac sarcoidosis

Cardiac sarcoidosis (CS) is a rare but potentially fatal condition that may present with a wide range of clinical manifestations including congestive heart failure, conduction abnormalities, and most notably, sudden death. Recent advances in imaging technology allow easier detection of CS, but the diagnostic guidelines with inclusion of these techniques have yet to be written. It has become clear that minimally symptomatic or asymptomatic cardiac involvement is far more prevalent than previously thought. Because of the potential life-threatening complications and potential benefit of treatment, all patients diagnosed with sarcoidosis should be screened for cardiac involvement. Patients with CS and symptoms such as syncope need an aggressive workup for a potentially life-threatening etiology, and often require implantable cardioverter-defibrillator therapy. CS patients without arrhythmic symptoms are still at risk for sudden death and may warrant an implantable cardioverter-defibrillator for primary prevention reasons. Although corticosteroids are regarded as the first-line drug of choice, therapy for CS is not yet standardized, and it is unclear at this point whether asymptomatic patients require therapy. Randomized clinical trials are clearly warranted to answer these very important patient care questions, and are endorsed fully by the authors.

Cardiac Sarcoidosis Presenting as Mitral Regurgitation

Cardiac sarcoidosis is most often clinically silent. When symptomatic, it commonly involves the conduction system. This inflammatory and infiltrative process may be manifest as conduction delays and/or important ventricular ectopy. More diffuse myocardial infiltration may result in congestive heart failure (CHF). This case report illustrates how a more focal infiltrative process in sarcoidosis may cause severe CHF with involvement of the papillary muscle, resulting in worsening of mitral regurgitation. After a cardiac workup that revealed evidence of sarcoidosis, a gadolinium-enhanced magnetic resonance imaging series showed focal infiltration of the left ventricular wall over the region of the posterior papillary muscle, giving a pathophysiologic explanation for the patient's severe mitral regurgitation. This case report depicts sarcoidosis-associated CHF arising in an unusual fashion, resulting not from widespread myocardial infiltration, but rather from focal papillary muscle involvement and, consequently, mitral valve dysfunction. This example suggests that cardiac sarcoidosis should be considered in the differential diagnosis of mitral regurgitation leading to progressive CHF. We briefly review the diagnostic approach to cardiac sarcoidosis, with representative images from this case.