Recurrent pleural and pericardial effusions due to sarcoidosis

Pleural and pericardial effusions with cardiac conduction system and myocardial involvement: A rare presentation of sarcoidosis

Sarcoidosis is a granulomatous immune disorder that can infiltrate many organ systems. When the cardiac system is involved, the myocardium and conduction system are frequently affected. We report the case of a patient presenting with complete heart block following cardioversion from atrial flutter accompanied by pleural and pericardial involvement whose diagnosis of sarcoidosis was subsequently made on pathological examination. Pericardial effusion and pleural effusion are rare manifestations of sarcoid, and the both of them happening simultaneously (less than 10 case reports) in conjunction with cardiac conduction system and myocardial involvement are almost nonexistent in the literature (one case report). As cardiac involvement in sarcoid can drastically increase the mortality, it is important to be vigilant for the diverse manifestations of cardiac involvement in all patients for which there is clinical suspicion of sarcoid.

Sarcoidosis presenting as acute pericarditis. A case report and review of pericardial sarcoidosis

Cardiac sarcoidosis typically involves the myocardium. Pericardial effusion is uncommon, and symptomatic pericardial disease is even more infrequent. We report the case of a patient presenting with pericarditis as the first manifestation of sarcoidosis. A 50-year-old previously healthy man presented with chest pain and dyspnoea. The electrocardiogram confirmed the diagnosis of pericarditis. Computed tomography of the thorax showed pulmonary infiltrates with mediastinal and hilar adenopathies. Histological analysis of a lymph node biopsy was consistent with sarcoidosis. There was no evidence of myocardial involvement on Magnetic Resonance Imaging (MRI). We reviewed the available English literature and identified 31 cases with sarcoidosis and pericardial involvement. The majority of cases presented as pericardial effusion, which was often the first clinical manifestation of the disease. Pathological diagnosis usually occurs at extra-cardiac locations. Myocardial involvement, an important cause of morbidity and mortality, was found in 25.8% (8/31) of cases. Sarcoidosis should be considered in the differential diagnosis of patients presenting with pericardial disease. The optimal treatment regimen and long-term outcome remain largely unknown. Research in cardiac sarcoidosis should include pericardial disease as a separate manifestation in order to improve the management of this rare but likely underdiagnosed condition.

Sarcoidosis associated pleural effusion: Clinical aspects

A sarcoidosis associated pleural effusion (SAPE) is a pleural effusion caused by active granulomatous inflammation from sarcoidosis. We describe the epidemiology, clinical features, diagnostic approach, treatment strategies and outcome of this condition. SAPE occurs in approximately 1% of sarcoidosis patients. The condition most commonly occurs at the initial presentation of sarcoidosis or within the first year. Dyspnea is the most common presenting symptom. Although a definitive diagnosis of SAPE requires a pleural biopsy, the diagnosis may be established on the basis of clinical features alone provided that alternative conditions can be reliably excluded. Pleural fluid analysis is essential in establishing the clinical diagnosis of SAPE. Corticosteroids are the drugs of choice for SAPE, and they are usually rapidly effective with courses of therapy often lasting less than two months. SAPE tends to have a low rate of recurrence that appears be to lower than for many other forms of sarcoidosis.

Idiopathic recurrent serositis-Off the beaten track

A 63-year-old female presented with chest pain and fever, and was found to have recurrent pleuropericardial effusions. Extensive investigations including infection screen and serologies, autoimmune screen and pleural and pericardial biopsy revealed no secondary aetiologies. She was diagnosed with idiopathic recurrent serositis (IRS). Our patient developed rash to naproxen, so she was started on colchicine monotherapy and responded well clinically. A review of the literature demonstrated that pleuropericardial effusions are rare occurrences, with patients occasionally being perceived as a medical enigma. This case study recommends an approach to guide physicians in their diagnosis and management of patients with pleuropericardial syndrome. Our case had an inflammatory phenotype, either autoimmune or seronegative serositis of unclear aetiology, which was recurrent and required pharmacological treatment. While the treatment for IRS lies in combined therapy with Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) and colchicine, monotherapy with colchicine was effective in the treatment and preventing recurrence in our unique case.

Abrupt Onset of Cardiac Tamponade in Sarcoidosis

Sarcoidosis is a systemic inflammatory disease characterized by the formation of noncaseating epithelioid granulomas. Multiple organs, including the lung, eyes, and skin, are involved in this disorder, and cardiac involvement is a major cause of morbidity and mortality in patients with this disorder. We present the case history of a 22-year-old man with neurosarcoidosis complicated by abrupt onset of cardiac tamponade. Cardiac tamponade is a rare but potentially fatal manifestation of sarcoidosis, which is treatable with glucocorticoid therapy. Including the present case, previously reported cases of sarcoidosis with cardiac tamponade are reviewed to delineate its clinical characteristics.

Associated Pleural and Pericardial Effusions: An Extensive Differential Explored

Concurrent pleural and pericardial effusions are not an unusual finding, but their differential diagnosis remains uncertain. Medline-based review identified an extensive list of infectious, inflammatory, neoplastic, iatrogenic, and myriad other etiologies. A single retrospective study had addressed this presentation. Several principles of a diagnostic workup are suggested, acknowledging that a significant minority of patients may not require a comprehensive workup and remain 'idiopathic'.

CASPA (CArdiac Sarcoidosis in PApworth) improving the diagnosis of cardiac involvement in patients with pulmonary sarcoidosis: protocol for a prospective observational cohort study

INTRODUCTION

Sarcoidosis is a multisystem disease, predominantly affecting the lungs but can involve the heart, resulting in cardiac sarcoidosis (CS). Patients require MRI/Positron Emission Tomography (PET) scans for diagnosis. Echocardiography, ECG and Holter monitoring may be indicative but not diagnostic alone. Patients can present late with conduction defects, heart failure or sudden death. The CASPA (CArdiac Sarcoidosis in PApworth) study protocol aims to (1) use MRI to identify CS prevalence; (2) use speckle-tracking echocardiography, signal averaged ECG and Holter monitoring to look for diagnostic pathways; and (3) identify serum proteins which may be associated with CS.

METHODS AND ANALYSIS

Participants with pulmonary sarcoidosis (and no known cardiac disease) from Royal Papworth Hospital will have the following: cardiac MRI with late gadolinium, two-dimensional transthoracic echocardiography with speckle tracking, signal averaged ECG and 24-hour Holter monitor. They will provide a serum sample for brain natriuretic peptide levels and proteomics by liquid chromatography coupled to high-resolution mass spectrometry. All data will be collected on OpenClinica platform and analysed approximately 6 months after final patient recruitment.

ETHICS AND DISSEMINATION

The Camden & Kings Cross Research Ethics Committee approved the protocol (REC number: 17/LO/0667). Integrated Research Approval System (IRAS) 222 720. Dissemination of findings will be via conference presentations and submitted to peer-reviewed journals.

Breaking hearts and taking names: A case of sarcoidosis related effusive-constrictive pericarditis

INTRODUCTION

Pericardial involvement of sarcoidosis is a rare cause for acute heart failure, and usually occurs as a result of the development of a pericardial effusion leading to cardiac tamponade. Even rarer still, is the manifestation of constrictive pericarditis. We report a case of sarcoidosis with lung, pleural, and pericardial involvement with effusive-constrictive pericarditis leading to cardiac tamponade.

CASE PRESENTATION

A 34-year-old Caucasian man presented for evaluation of a history of worsening exertional dyspnea, edema, and weight loss. A high-resolution chest computed tomography showed diffuse pulmonary nodules with upper lobe predominance and in a perilymphatic distribution; large right pleural effusion; and large pericardial effusion with pericardial thickening. A transthoracic echocardiogram demonstrated early tamponade physiology for which a pericardial drain was placed. After removal of the drain he developed cardiogenic shock from cardiac tamponade attributed to the reaccumulation of a pericardial effusion and urgent pericardial window was performed. Serial echocardiography was concerning for organization and localization of the pericardial fluid. Cardiac magnetic resonance imaging demonstrated a significant reduction in pericardial slippage between the parietal and visceral layers around the heart collectively suggestive of constrictive pericarditis. Confirmation of effusive-constrictive pericarditis was noted on right heart catheterization. He then underwent pericardiectomy, which on histopathologic evaluation demonstrated non-necrotizing granulomas, thus confirming pericardial involvement of sarcoidosis.

CONCLUSIONS

We report a case demonstrating unique manifestations of sarcoidosis; effusive-constrictive pericarditis presenting with acute congestive heart failure.

Cardiac sarcoidosis - an expert review for the chest physician

Introduction: Sarcoidosis is a multisystem granulomatous disease predominantly affecting the lungs, with increased risk of cardiovascular disease, pulmonary hypertension and cardiac sarcoidosis (CS), the latter due to direct granuloma infiltration. Sarcoidosis is often managed by chest physicians who need to understand the diagnostic pathways and initial management plans for patients with cardiac involvement. Areas covered: The most serious consequence of CS is sudden cardiac death due to ventricular tachyarrhythmias or complete atrioventricular block. Additional complications include atrial arrhythmias and congestive cardiac failure. There are no internationally accepted screening pathways, but a combination of history, clinical examination and ECG detects up to 85% of cases. Newer modalities including signal-averaged ECG and speckle-tracking echocardiography increase identification of patients who require a definitive diagnosis. Early immunosuppression reduces the risk of conduction abnormalities and incidence of supraventricular arrhythmias. Management of ventricular arrhythmias requires antiarrhythmic medications followed by possible catheter ablation and device (ICD) implantation. Expert commentary: Prospective trials are underway to identify the optimum methods for screening, which will guide future international statements on indications for and methods of screening in CS.

Cardiovascular MRI of the pericardium: A case review of the anatomy, scan protocols and pathology of the pericardium

The aim of this article was to present a case based review of the anatomy, scan protocols and pathology of the pericardium. Cardiovascular magnetic resonance imaging provides excellent anatomic depiction of the pericardium, vital information on myocardial infiltration and characterisation of mass lesions and pericardial effusions. It adds valuable information in the assessment of complicated pericardial disease.

Sarcoidosis misdiagnosed as malignant tumors: a case report

Background

Sarcoidosis is a rare condition that is often misdiagnosed as malignant tumors due to the similar clinical manifestations and imaging findings.

Case Presentation

We encountered a 56-year-old Chinese woman who had a chief complaint of a persistent cough. The chest computer tomography (CT) revealed mediastinal and bilateral hilar lymph node enlargement, and positron emission tomography-computer tomography (PET-CT) revealed abnormal fluorodeoxyglucose (FDG) uptake in the lymph nodes of the chest and abdomen. To further clarify the diagnosis, a lymph node sampling was performed by video-assisted thoracoscopic surgery (VATS) and the histopathologic diagnosis of sarcoidosis was confirmed.

Conclusions

VATS could be an effective and minimally invasive diagnostic method to discriminate pulmonary sarcoidosis with other malignant tumors.

Cardiac sarcoidosis: diagnosis and management

Cardiac sarcoidosis is one of the most serious and unpredictable aspects of this disease state. Heart involvement frequently presents with arrhythmias or conduction disease, although myocardial infiltration resulting in congestive heart failure may also occur. The prognosis in cardiac sarcoidosis is highly variable, which relates to the heterogeneous nature of heart involvement and marked differences between racial groups. Electrocardiography and echocardiography often provide the first clue to the diagnosis, but advanced imaging studies using positron emission tomography and MRI, in combination with nuclear isotope perfusion scanning are now essential to the diagnosis and management of this condition. The identification of clinically occult cardiac sarcoidosis and the management of isolated and/or asymptomatic heart involvement remain both challenging and contentious. Corticosteroids remain the first treatment choice with the later substitution of immunosuppressive and steroid-sparing therapies. Heart transplantation is an unusual outcome, but when performed, the results are comparable or better than heart transplantation for other disease states. We review the epidemiology, developments in diagnostic techniques and the management of cardiac sarcoidosis.

[Sarcoid pleural effusion]

Pleural effusion (PE) is a very uncommon manifestation of sarcoidosis. It is equally observed in men and women, can appear at any age and in all radiologic stages, though it is more common in stages i and ii. Effusions have usually a mild or medium size and mainly involve the right side. Various mechanisms can be implicated. PE will be a serous exudate if there is an increase in the capillary permeability due to direct involvement of the pleural membrane, a chylothorax if mediastinum lymph nodes compress the thoracic duct and/or the lymphatic drainage from the pleural cavity, an hemothorax if granuloma compress or invade pleural small vessels or capillaries, and even a transudate if there is compression of the inferior vena cava, atelectasis due to complete bronchial obstruction or when the resolution of the PE is incomplete with chronic thickening of visceral pleura (trapped lung). It manifests biochemically as a pauci-cellular exudate with a predominance of lymphocytes, though there can be a preponderance of eosinophils or neutrophils. Protein concentrations are usually proportionately higher than lactate dehidrogenase, adenosine deaminase is normally low and it is possible to find increased levels of CA-125 in women. The tuberculin test is negative and pleural or lung biopsies yield the diagnosis by confirming the presence of non-caseating granulomata. These PE can have a favorable self-limited outcome, even though in most cases treatment with corticosteroids is needed, while surgery is required in a few cases.

Cardiac tamponade as an initial manifestation of systemic lupus erythematosus

Clinical manifestations of pericardial disease may precede other signs and symptoms associated with systemic lupus erythematosus. Although pericardial effusion is one of the most common cardiac problems in patients with systemic lupus erythematosus, haemodynamically significant effusions manifesting as cardiac tamponade are rare and require prompt diagnosis and treatment.

A 50-year-old man with stage 2 sarcoidosis with pleural involvement

We present a case of a 50-year-old man who presented with progressive shortness of breath, cough, chest pain, and weight loss. His computer tomography (CT) scan of the chest showed a left-sided pleural effusion, subpleural and peribronchovascular nodules, bilateral hilar and mediastinal lymphadenopaties. Traasbronchial biopsies of the lung parenchyma and Video-Assisted Thoracoscopic Surgery (VATS) with pleural biopsies revealed the presence of noncaseating granulomas. A diagnosis of stage 2 sarcoidosis with pleural involvement was made and treatment with prednisone was started. The patient continued with persistent dyspnea and a left-sided pleural effusion. Steroid treatment was tapered and leflunomide therapy was initiated. A significant improvement of his clinical condition was seen after 1 month on treatment.