Isolated cardiac sarcoidosis presenting as transient ischemic attack

Abstract

Key clinical message: Isolated cardiac sarcoidosis may rarely present with TIA or stroke as an initial clinical manifestation. This case highlights the necessity of a broad differential and a high degree of suspicion for cardiac sarcoidosis in a patient with new neurologic symptoms and evidence of cardiac disease.

Abstract: Cardiac sarcoidosis is a rare disease with a variety of clinical manifestations including heart failure and sudden death. Stroke as the earliest sign of disease has been described in rare cases. We present a case of a 54-year-old female with recurrent transient ischemic attacks (TIAs) of unknown etiology, initially in the absence of left ventricular dysfunction. Cardiomyopathy was later identified on echocardiography after a second TIA. Cardiac MRI was remarkable for focal left ventricular wall thinning with akinesis and dyskinesis of multiple wall segments, a right ventricular aneurysm, and diffuse myocardial late gadolinium enhancement. PET/CT showed multifocal areas of myocardial FDG uptake. At follow-up, echocardiography showed a left ventricular apical thrombus, in a previously identified thinned, akinetic region, suggesting cardioembolic origin for previous TIAs. She was started on anticoagulation therapy, prednisone, methotrexate, and adalimumab, with resolution of the thrombus and improvement in cardiac function. In conclusion, this case highlights the need to consider CS as a potential cause of cerebrovascular ischemic events in patients with few stroke risk factors but findings indicative of cardiac disease. It is essential to further explore the mechanisms behind these events and develop treatments that target their causes in this patient population.

Keywords: TIA; cardiomyopathy; sarcoidosis; stroke.

FIGURE 1

Transthoracic echocardiogram with contrast showing wall motion abnormalities in inferoseptal, basal inferior walls, and apex, with associated pooling of contrast (yellow arrows), on diastole (left) and systole (right). RV, right ventricle, LV, left ventricle.

FIGURE 2

(A) Cardiac magnetic resonance demonstrating a right ventricular aneurysm (yellow arrow) measuring 12.8 mm by 9.3 mm, apical akinesis and myocardial thinning in apex (yellow arrow heads), inferoseptal, and anteroseptal walls, and heterogenous delayed gadolinium enhancement throughout the myocardium, including the thinned, akinetic regions (white arrow heads). (B) Fluorodeoxyglucose positron emission tomography/computed tomography showing patchy nodular areas of tracer uptake in myocardium, corresponding to structurally abnormal areas in cardiac magnetic resonance.

FIGURE 3

Apical thrombus measuring 0.8 cm × 0.6 cm visualized in akinetic cardiac apex, in diastole (left) and systole (right). LV, left ventricle.