Abstract 18558: A Puzzling Case of Dyspnea on Exertion
A 59 year-old Caucasian male with a past medical history of presumed pulmonary sarcoidosis, asthma, hypothyroidism, and allergic rhinitis presented to our institution with dyspnea on exertion. One year prior to this hospital presentation, the patient was seen by his primary care physician for progressive dyspnea on exertion. He was sent for a computed tomography scan of the chest which revealed extensive hilar and mediastinal lymphadenopathy. Ultimately, he underwent a biopsy of his hilar lymph nodes which revealed extensive noncaseating granulomas, leading to a diagnosis of pulmonary sarcoidosis. He was started on a regimen of oral corticosteroids (prednisone) to which he experienced a moderate improvement (but not complete amelioration) in symptoms. On this admission, our patient had a 2D transthoracic echocardiogram which revealed mild concentric left ventricular hypertrophy (LVH), a subtle “septal bounce”, and annulus reversus (septal tissue Doppler e’ > lateral tissue Doppler e’). A recent cardiac magnetic resonance imaging (MRI) study the patient had to evaluate for the presence of cardiac sarcoidosis was examined and, in retrospect, was notable for pericardial thickening as well as calcifications. Given mounting evidence for the presence of constrictive pericarditis, we proceeded to a left and right heart catheterization and coronary angiogram. This revealed 1) steep right atrial “y” descent 2) diastolic equalization of RV and LV diastolic pressures 3) “dip and plateau” configuration of LV and RV pressures and 4) discordance of LV and RV pressures during respiration, all suspicious for the presence of constrictive pericarditis. A thorough search for etiologies of constrictive pericarditis revealed two differential diagnoses: sarcoidosis and cardiac involvement of Whipple’s disease. The patient proceeded to radical pericardiectomy with biopsies revealing pericardial and myocardial infiltration by Periodic-acid Schiff (PAS) stain positive macrophages concerning for cardiac Whipple’s disease. A sample was sent to the Centers for Disease Control for immunofluorescence testing which ultimately confirmed the diagnosis. The patient was placed on high-dose ceftriaxone therapy for Whipple’s disease.
Author Disclosures: S. Adusumalli: None. N.P. Chokshi: None.
- © 2016 by American Heart Association, Inc.