Case 2
A 51 year old male, with no chronic illnesses was seen with a 4 month history of intermittent dry cough, palpitations and progressive shortness of breath on exertion. He had received treatment for recurrent chest infections and was a lifelong non-smoker. He was referred to the respiratory clinic with an abnormal CXR. Clinical examination revealed bilateral lower lung zones crepitations, SpO2 of 94% at rest and on room air with exertional drop to 88%. He had a regular bradycardia of 35 beats/min and blood pressure of 137/74 mmHg. ECG revealed a third degree heart block (Figure 3). His transthoracic echocardiogram showed normal LV morphology (relative wall thickness, 0.32; LV mass index, 91 g/m2); normal systolic and diastolic function, and normal segmental wall motion. There was complete atrioventricular block with junctional escape rhythm as well as intermittent Mobitz type I or 2 block on his 24 hour Holter ECG. A high resolution chest CT-Scan showed ground glass opacification with multiple tiny nodules in the mid and lower lung zones, increased reticulation and mediastinal lymphadenopathy suggestive of Stage II sarcoidosis. Serum ACE was elevated; 116.0 IU/L (8.0 – 52.0) and pulmonary function test showed a restrictive pattern with a FEV1 of 2.23L (predicted, 3.64), FVC of 2.53L (predicted, 4.68) and a FEV1/FVC ratio of 88.3% (predicted, 77.7%). A diagnosis of pulmonary sarcoidosis with probable cardiac involvement was made and confirmed by Cardiac MRI which revealed Late Gadolinium enhancement of the mid-septum, basal to mid-septum and lateral LV wall with corresponding oedema and inflammation in STIR images highly suggestive of cardiac sarcoidosis (Figure 4).
Patient was started on corticosteroid and azathioprine and assessed for a possible pacemaker insertion which patient refused. He however showed marked improvement in the respiratory symptoms and a conversion of the complete heart block to a first degree heart block after 8 weeks of therapy (Figure 5). He is being followed up periodically with ECGs.