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When Dyspnea Is Not Just Dyspnea

Case Editor - Judd Flesch

Reviewed By Clinical Problems Assembly

Submitted by

Khadir Kakal, MD

Fellow, Physician

University of Southern California, Keck School of Medicine

Division of Pulmonary, Critical Care and Sleep Medicine

Los Angeles, CA

Richard Lubman, MD

Associate Professor of Clinical Medicine

University of Southern California, Keck School of Medicine

Division of Pulmonary, Critical Care and Sleep Medicine

Los Angeles, CA

Kamyar Afshar, DO

Assistant Professor of Clinical Medicine

University of Southern California, Keck School of Medicine

Division of Pulmonary, Critical Care and Sleep Medicine

Los Angeles, CA

Submit your comments to the author(s).

History

A 50 year-old man presents to clinic with complaints of dyspnea on exertion of 3-week duration. He denies any significant dyspnea on exertion on a flat surface, but does have some limitations on an incline. He denies any associated cough, hemoptysis, chest pain or orthopnea. He is without any constitutional symptoms.

The patient has been otherwise asymptomatic.  He describes being hospitalized for an episode of pneumonia 13 years ago, but otherwise has no history of asthma, COPD, tuberculosis, coccidioidomycosis or other respiratory diseases.  He has no prior history of cardiac disease.  He was born in Glendora, CA and has lived in the Los Angeles area his entire life.  He has no history of travel-related illness or recent travel.  He is a retired electrician with no known history of exposure to asbestos or other occupational or environmental hazards.  He is a lifelong non-smoker.

Physical Exam

The patient is in no acute distress. Vitals are remarkable for bradycardia with a pulse of 40/minute. Otherwise, there is no hypotension or tachypnea. Lungs are clear to auscultation bilaterally without rales, rhonchi or wheezes. Cardiac examination demonstrated sinus bradycardia without murmur, rubs or gallops. The remaining physical examination was unremarkable.

Diagnostic Tests

image 1

An Electrocardiogram was done which showed complete heart block.

 

image 2

Chest radiograph was devoid of any pulmonary pathology

 

Echocardiogram

Normal Left ventricular size with low normal systolic function and no regional wall motion abnormalities. Estimated EF 55%

Mild concentric LVH and 2/4 diastolic dysfunction

Right ventricle was moderately dilated, with normal systolic function

Biatrial enlargement

No valvular abnormalities

No pericardial effusion

Lab

WBC 4,900 per mm3

Hematocrit 45.3%

Platelets 150,000 per mm3

Sed rate 8

Potassium 4.0 mmol/L

TSH 2.0

Lyme Antibody Screen negative

ACE level 47 (9-67)

Question 1

There was a suspicion for cardiac sarcoidosis. Which test is the most sensitive in diagnosing cardiac sarcoidosis?


References

  1. Michael C. Iannuzzi, M.D., Benjamin A. Rybicki, Ph.D., and Alvin S. Teirstein, M.D; Sarcoidosis; N Engl J Med 2007; 357:2153-2165
  2. Uemura et al, Histologic diagnostic rate of cardiac sarcoidosis: evaluation of endomyocardial biopsies; Am Heart J. 1999 Aug;138(2 Pt 1):299-302
  3. Kim et al, Cardiac Sarcoidosis, Am Heart J 2009;157:9-21
  4. Smedma JP, et al. Evaluation of the accuracy of gadolinium-enhanced CMR in the diagnosis of cardiac sarcoidosis. J Am Coll Cardiol 2005;45:1683-1690
  5. Roberts WC, McAllister HA Jr., Ferrans VJ, et al. Sarcoidosis of the heart. A clinicopathologic study of 35 necropsy patients (group I) and review of 78 previously described necropsy patients (group II). Am J Med 1977;63:86–108.
  6. Youssef et al, CS: applications of imaging in diagnosis and directing treatment. Heart 2011;97:2078-2087
  7. Yazaki Y, Isobe M, Hiroe M, et al. Prognostic determinants of long-term survival in Japanese patients with cardiac sarcoidosis treated with prednisone. Am J Cardiol 2001;88:1006-1010