What Explains This Young Man’s Palpitations?
Author:
Andrew Freeman, MD
National Jewish Health
A 39‑year‑old black man with no remarkable medical history presented to his primary care physician with heart palpitations, which had occurred a couple times per day over the past few weeks. The patient reported brushing off the palpitations, initially attributing them to drinking too much coffee or not getting enough sleep. However, after a few weeks of these events, the patient decided to get it checked out by his primary care physician.
The primary care physician ordered chest radiography, the results of which ruled out upper respiratory tract infection but showed a small degree of hilar fullness. The patient was referred to a cardiologist and a pulmonologist for further workup.
The pulmonologist initially thought it could be a reactive lymphadenopathy from a recent infection. After a couple of months, the patient revisited the pulmonologist to repeat the chest radiography; the hilar fullness persisted.
Meanwhile, the cardiologist had ordered an echocardiogram and Holter monitor. The results of the echocardiogram showed that his ejection fraction was mildly reduced, at about 45% (normal range, 53%-73%). His Holter monitor data showed occasional short runs of ventricular tachycardia.
Once the pulmonologist saw the results of these tests, as well as the patient’s persistent hilar lymphadenopathy, the pulmonologist ordered a transbronchial biopsy. The cardiologist also ordered a cardiac magnetic resonance imaging (cMRI) scan, the results of which showed areas of delayed hyperenhancement, particularly involving the basal septum of the heart.
ANSWER: CARDIAC SARCOIDOSIS
The diagnosis of sarcoidosis with cardiac involvement, or cardiac sarcoidosis, was made. The results of the transbronchial biopsy of the patient’s hilum showed noncaseating granulomas, which are consistent with sarcoidosis. The hilar lymphadenopathy was also a clue, particularly in a young black man. That puts sarcoidosis much higher on the differential. With the tissue diagnosis from biopsy, this was the most likely culprit.
The Holter monitor provided insights into the type of arrhythmia found and can often be used to rule out arrhythmia. In this case, abnormal monitoring revealed ventricular tachycardia, which is in fact what the patient had, but the next question is, “Why did he have ventricular tachycardia?”
Putting all of the above into context helps to illustrate looking at the patient as a whole, and in this case, granulomatous involvement of cardiac sarcoidosis was the likely cause of the patient’s cardiomyopathy and arrhythmia (ventricular tachycardia).
It should be noted, that patients with systemic sarcoidosis can have cardiac involvement in up to about 30% of the cases, and when symptoms are present, they are a clue that this should be investigated promptly. Sometimes cardiac sarcoidosis can present as sudden cardiac death, which is an important issue that requires surveillance.
PATIENT OUTCOME
The patient was initially prescribed steroids and then eventually was prescribed an immunosuppressive drug and a disease‑modifying antirheumatic drug. The patient’s ejection fraction significantly improved to within the normal range. His palpitations subsided quite drastically, and the hilar lymphadenopathy improved slightly. The patient felt better overall.
Andrew M. Freeman, MD, FACC, FACP, is an associate professor, director of Cardiovascular Prevention and Wellness, and director of Clinical Cardiology & Operations in the Division of Cardiology in the Department of Medicine at National Jewish Health in Denver, Colorado.