Cardiac Sarcoidosis Masquerading as Syncope With Right Ventricular Septal Mass

Abstract: Cardiac sarcoid remains a challenging diagnostic entity. Electrical abnormalities in sarcoid myocarditis range from heart blocks to lethal ventricular tachycardias. Sarcoid granulomas have predilection for left ventricular side and basal septum in cardiac involvement. We present a case of sarcoid myocarditis presenting as mass involving the entire right ventricular side of the interventricular septum. 

J INVASIVE CARDIOL 2012;24(8)418-419

Key words: cardiac tumor, ventricular arrhythmia

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A 45-year-old African American male presented with syncope and palpitations. His electrocardiogram in the emergency department showed tachycardia (QRS duration, 114 ms) (Figure A) resistant to adenosine (max bolus dose, 24 mg). Sustained tachycardia resulted in hypotension and rhythm likely to be fascicular ventricular tachycardia was cardioverted into sinus rhythm. He subsequently had non-sustained wide complex tachycardia (Figure B) in the coronary care unit. Echocardiogram showed a mass on the right interventricular septum (Figure C and D). He continued to have intermittent bouts of ventricular tachycardia while on intravenous amiodarone drip after amiodarone bolus. Coronary arteriography showed normal arteries. Cardiac magnetic resonance imaging bright blood sequence showed hyperintense soft tissue mass on the right ventricular side of the interventricular septum (Figure E and F). Computed tomography showed parahilar lymph node enlargement. Transbronchial fine-needle aspiration biopsy of parahilar lymph node confirmed non-caseating granulomas consistent with sarcoidosis (Figure G). The patient’s arrhythmia responded to steroid treatment.

Electrial abnormalities in sarcoid myocarditis range from bradyarrhythmias to tachyarrhythmias. Abnormal automaticity is the likely mechanism of ventricular arrhythmia in sarcoidosis. Electrocardiographic abnormalities correlate strongly with the severity of cardiac involvement, with complete heart block and ventricular tachycardia being the most fatal. Endomyocardial biopsy has a low diagnostic yield because cardiac involvement tends to be patchy, and granulomas are more likely to be located in the left ventricle and basal ventricular septum than in the right ventricle. To our knowledge, this is first case of sarcoid myocarditis presenting as a mass involving the entire right ventricular side of the interventricular septum. 

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From the Department of Medicine, Division of Cardiology, Central Arkansas Veterans Healthcare System and University of Arkansas for Medical Sciences, Little Rock, Arkansas.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Sachdeva serves on the Speaker’s Bureau for St Jude Medical and Volcano Corporation. The other authors report no disclosures.
Manuscript submitted January 4, 2012 and accepted February 20, 2012.
Address for correspondence: Rajesh Sachdeva, MD 4300 W 7th Street, Little Rock, AR 72205. Email: rrsachdeva@gmail.com and rsachdeva@uams.edu