Scintigraphic detection of regional disruption of the adrenergic nervous system in sarcoid heart disease

The Burden of Neurosarcoidosis: Essential Approaches to Early Diagnosis and Treatment

Neurosarcoidosis (NS) is an often severe, destructive manifestation with a likely under-reported prevalence of 5 to 15% of sarcoidosis cases, and in its active phase demands timely treatment intervention. Clinical signs and symptoms of NS are variable and wide-ranging, depending on anatomical involvement. Cranial nerve dysfunction, cerebrospinal parenchymal disease, aseptic meningitis, and leptomeningeal disease are the most commonly recognized manifestations. However, non-organ-specific potentially neurologically driven symptoms, such as fatigue, cognitive dysfunction, and small fiber neuropathy, appear frequently.Heterogeneous clinical presentations and absence of any single conclusive test or biomarker render NS, and sarcoidosis itself, a challenging definitive diagnosis. Clinical suspicion of NS warrants a thorough systemic and neurologic evaluation hopefully resulting in supportive extraneural physical exam and/or tissue findings. Treatment targets the severity of the manifestation, with careful discernment of whether NS reflects active potentially reversible inflammatory granulomatous disease versus inactive postinflammatory damage whereby functional impairment is unlikely to be pharmacologically responsive. Non-organ-specific symptoms are poorly understood, challenging in deciphering reversibility and often identified too late to respond to conventional immunosuppressive/pharmacological treatment. Physical therapy, coping strategies, and stress reduction may benefit patients with all disease activity levels of NS.This publication provides an approach to screening, diagnosis, disease activity discernment, and pharmacological as well as nonpharmacological treatment interventions to reduce disability and protect health-related quality of life in NS.

Usefulness of 67Ga SPECT and integrated low-dose CT scanning (SPECT/CT) in the diagnosis of cardiac sarcoidosis

OBJECTIVE

We performed 67Gallium (Ga) single-photon emission computed tomography (SPECT) with integrated low-dose computed tomography (CT) for the interpretation of myocardial outline to investigate the value of co-registered fusion imaging using a hybrid system (SPECT/CT) in patients with cardiac sarcoidosis.

METHODS

SPECT/CT of the region in question was performed with VG Hawkeye. The subjects in this study were 37 patients [mean (+/-SD) age 61.0+/-13.0 years; 12 men and 25 women], 13 of whom had a clinical diagnosis of cardiac sarcoidosis and 24 a negative diagnosis. An intravenous injection of Ga (dosage 111 MBq) was performed on patients 48 h or 72 h before obtaining static planar images of the whole-body and the SPECT/CT scan.

RESULTS

Abnormal Ga uptake in the myocardium was observed in 10 of the 13 subjects with true sarcoidosis, and in 11 of 24 with negative sarcoidosis without CT fusion. The sensitivity without CT fusion was 77%, the specificity 54%, and the accuracy 62%. Use of SPECT/CT changed the diagnosis only in a patient with true sarcoidosis, and changed the diagnosis in eight patients with negative sarcoidosis. The sensitivity with CT fusion was 69%, the specificity 79%, and the accuracy 76%. The difference in diagnostic accuracy was statistically significant (McNemar's test, P=0.039).

CONCLUSIONS

SPECT scanning using Ga and integrated low-dose CT is a very useful diagnostic imaging technique because it improves the diagnostic specificity of Ga SPECT to allow the highly specific diagnosis of cardiac sarcoidosis.

Heart rate variability in sarcoidosis: a frequency domain analysis

BACKGROUND: Little is known about autonomic dysfunction in patients with sarcoidosis. Heart rate variability (HRV) studies provide information regarding sympathetic and vagal tone and are both noninvasive and relatively simple to perform. The objective of this study was to compare HRV in sarcoidosis patients and in healthy controls. METHODS: We prospectively analyzed data from 12 sarcoidosis patients and 12 healthy volunteers. Electrocardiographic (ECG) data were recorded from all study participants, and HRV analysis was performed in the frequency domain. The sarcoidosis patients underwent echocardiography as well. RESULTS: Mean values for HRV in the high-frequency (HF) domain were significantly reduced in sarcoidosis patients (182+/-102 ms(2) vs. 758+/-457 in controls, p=0.001). We also observed a trend (p=0.055) towards an increased ratio of low-frequency (LF) to high-frequency power in sarcoidosis patients. CONCLUSIONS: Our findings indicate the possibility of altered sympathovagal balance in sarcoidosis. Since 5 of these 12 sarcoidosis patients had mild echocardiographic abnormalities, possibly related to sarcoidosis, we were unable to conclude whether the HRV findings were attributable solely to an autonomic dysfunction in sarcoidosis or whether they were related to a structural myocardial involvement of the disease.

Cardiac sarcoidosis: a retrospective study of 41 cases

This retrospective study concerned 18 female and 23 male patients with cardiac sarcoidosis (CS). The average age at CS diagnosis was 38 years. CS was observed in white (73% of cases) and in black or Caribbean patients (27% of cases). All patients had extracardiac histologic proof of sarcoid tissue. In 63% of cases, the CS arose during the follow-up of systemic sarcoidosis. Systemic sarcoidosis was not specific except for a high frequency of neurosarcoidosis. Revealing cardiac signs were clinical in 63% of cases and electrical in 22%. In most patients these signs were associated with an abnormal echocardiography (77%) and/or a defect on thallium-201 or sestamibi imaging (75%). Thirty-nine patients received steroid therapy (initial dose mostly equal to 1 mg/kg per day), associated in 13 cases with another immunosuppressive treatment. In 26% of cases the immunosuppressive treatment was associated with a specific cardiac treatment. In the long-term follow-up (average follow-up, 58 mo), 87% of the cases showed an improvement, and 54% were cured from a clinical and laboratory point of view (electrocardiogram, 24-hour monitoring, echocardiography, radionuclide imaging). There was no sudden death. Two patients worsened, which can be explained in 1 case by very late treatment and in the other case by lack of treatment, except for a pacemaker. Our experience leads us to treat CS with corticosteroids as soon as possible and to use another immunosuppressive treatment where there is an insufficient therapeutic response or where there are contraindications to corticosteroids.

Detection of denervated but viable myocardium in cardiac sarcoidosis with I-123 MIBG and Tl-201 SPECT imaging

A 58-year-old man, who had biopsy-proven cardiac sarcoidosis, underwent TI-201 and I-123 MIBG cardiac scintigraphy. Although no perfusion defect was identified by Tl-201, mild heterogeneity of I-123 MIBG uptake was present in the myocardium. The denervated but viable myocardium was demonstrated in the heart with sarcoidosis. Cardiac sympathetic nerve function was impaired in cardiac sarcoidosis, slightly improved with steroid therapy. I-123 MIBG scintigraphy may be useful to assess extent of myocardial involvement and response to therapy.