Case Report
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Jun 26, 2020; 12(6): 291-302
Published online Jun 26, 2020. doi: 10.4330/wjc.v12.i6.291
Exercise-induced torsades de pointes as an unusual presentation of cardiac sarcoidosis: A case report and review of literature
Chadi Ghafari, Frédéric Vandergheynst, Emmanuel Parent, Kaoru Tanaka, Stéphane Carlier
Chadi Ghafari, Emmanuel Parent, Stéphane Carlier, Department of Cardiology, Centre Hospitalier Universitaire Ambroise Paré, Mons 7000, Belgium
Chadi Ghafari, Stéphane Carlier, Department of Cardiology, Université de Mons, Mons 7000, Belgium
Frédéric Vandergheynst, Department of Internal Medicine, Cliniques Universitaires de Bruxelles - Erasme, Bruxelles 1070, Belgium
Kaoru Tanaka, Department of Cardiology, Universitair Ziekenhuis Brussels, Jette 1090, Belgium
Author contributions: All authors contributed equally in the conception and design of the paper, the literature review and discussion, the drafting, critical revision and editing of the manuscript, and providing approval of the final version.
Informed consent statement: Informed consent was obtained from the patient for publication of this report.
Conflict-of-interest statement: The authors report having no potential conflicts of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016) and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Stéphane Carlier, MD, PhD, Professor, Department of Cardiology, Université de Mons, Avenue du Champ de Mars 8, Mons 7000, Belgium. stephane.carlier@umons.ac.be
Received: February 17, 2020
Peer-review started: February 17, 2020
First decision: March 15, 2020
Revised: March 26, 2020
Accepted: May 15, 2020
Article in press: May 15, 2020
Published online: June 26, 2020
Processing time: 130 Days and 16.4 Hours
Abstract
BACKGROUND

Sarcoidosis is a rare multisystem disease characterized histologically by non-caseating granuloma formation in the affected organ. While cardiac sarcoidosis is found on autopsy in up to 25% of sarcoidosis cases, it is still underdiagnosed and is associated with a poor prognosis. Although the etiology of sarcoidosis remains unclear, an antigen triggered exaggerated immune response has been hypothesized. Early detection and prompt management of cardiac sarcoidosis remains pivotal.

CASE SUMMARY

A 60-year-old female, with pulmonary sarcoidosis in remission, presented to the cardiology outpatient clinic for evaluation of weeks-long dyspnea on moderate exertion (New York Heart Association class II) that was relieved by rest. Submaximal exercise stress test showed multifocal ventricular extrasystoles, followed by a self-limiting torsades de pointes. Cardiac magnetic resonance imaging showed nondilated and normotrophic left ventricle with basoseptal and mid-septal dyskinesis. The magnetic resonance imaging-derived left ventricular ejection fraction was 45%. Delayed enhancement showed patchy transmural fibrosis of the septum and hyperenhancement of the papillary muscles, all in favor of extensive cardiac involvement of sarcoidosis. A double-chamber implantable cardiac defibrillator was implanted, and methylprednisolone (12 mg/d) and methotrexate (12.5 mg/wk) treatment was initiated. Follow-up and implantable cardiac defibrillator interrogation showed episodes of asymptomatic nonsustained ventricular tachycardia and an asymptomatic episode of nonsustained ventricular tachycardia ending by the first antitachycardia pacing run.

CONCLUSION

Along an extensive review of the literature, this unusual case report highlights the importance of early detection of cardiac involvement of sarcoidosis, in order to avoid potential complications and increase survival.

Keywords: Sarcoidosis, Cardiac sarcoidosis, Torsades de pointes, Ventricular tachycardia, Immunotherapy, Case report

Core tip: Cardiac sarcoidosis (CS) remains an underdiagnosed illness bearing a poor prognosis. While a number of reviews in the literature have tackled the treatment of CS, no published guidelines and only consensus publications of global experts’ opinions are available for the diagnosis. Our objective with this case report and literature review was to consolidate the available literature for a better delineation of the diagnosis and treatment of CS.