The patient is a 40 year old African-American female with no significant past medical history who presented to the ED with a 2 week history of lower extremity edema and shortness of breath. She also noticed intermittent palpitations, dry cough, easy fatigue and a 30 pound weight loss. On examination, the patient’s temperature was 98.9F orally, pulse was 155-170 beats per minute, and blood pressure was 133/93 mmHg. EKG revealed long P-R tachycardia with heart rate of 170. Chest X- ray was done and showed large right pleural effusion with compressive atelectasis and small left pleural effusion. Transthoracic echocardiogram at the time of admission was consistent with severe global LV dysfunction with EF-20% and moderate pulmonary hypertension. CT Chest, which showed bilateral hilar adenopathy and subsequent biopsy was consistent with non-caseating granulomatous lesion. Her initial basic laboratory values, including TSH level, were normal except for BNP which was 569. She underwent left and right heart catheterization, which revealed normal coronary arteries and decreased cardiac index. During the hospital stay, telemetry monitors revealed rhythms consistent with various degrees of AV conduction abnormalities. She was started on steroids and intravenous milrinone for possible sarcoid cardiomyopathy and listed for heart transplant. Her symptoms were gradually improved and she was discharged home with steroids, beta blockers, diuretics, ace inhibitors and an implantable defibrillator. She is currently followed as an outpatient and doing extremely well without any cardiac symptoms.
Srinivasan, MD, Sivakumar and Chryssos, MD, Emanuel
The Medicine Forum:
Vol. 7, Article 16.
Available at: http://jdc.jefferson.edu/tmf/vol7/iss1/16