The Common Vein

 

Hi Prashanth

SARCOIDOSIS, a SCARE, CHEST PAIN and an OCTOPUSRe “Sarcoidosis, a Scare, Chest Pain and an Octopus”

This is a story about a 59 year  old woman who had sarcoidosis, who had a scare developed chest pain that sounded like acute coronary syndrome and was short of breath

Your part is to review our patient CXR CT MRI in 4 minutes!

Below is now the stream lined version of your part and the aim is for you to use the presentations of previous participants to decide whether the CXR is CHF or sarcoidosis, interpret the CT and angios, and then the MRI
Coming before you are;

Will who  is doing CXR and Sarcoid
Michael CHF
Hoon – Chest sarcoidosis and CT
Pedro  cardiac sarcoidosis and MRI
Maryam  normal coronary anatomy

Let me know about any reservations or questions

Thanks

 

59-year-old female with a history of sarcoidosis (cutaneous, ocular and pulmonary).

Solid nodules along right major fissure and subpleural nodules anterior lingula in characteristic location

PLEURAL and FISSURAL BASED LUNG NODULES (red arrows)
Chest CT showed multiple non calcified nodules.

 

Right Sided Centrilobular Nodules and Left Major Fissure Nodule

CENTRILOBULAR NODULE (green arrow) PARENCHYMAL NODULE (yellow) and FISSURAL NODULE (red arrow)

Pawnbrokers Sign – 1,2,3 Sign

Bilateral hilar adenopathy is most common and usually symmetric (50 percent of cases) or the right may be slightly more prominent . Unilateral adenopathy is uncommon (<5 percent of cases).

PAWNBROKER or 1,2,3 SIGN

CAD

CORONARY CALCIFICATION including L MAIN

Her current presentation;

1 hour of substernal chest pain, associated with dyspnea, precipitated by an encounter with the police who needed to search her house.

CXR

CHF or Stage II Sarcoidosis?

CHF and CXR or Sarcoidosis and CXR  as per prior discussion

Is the LA Enlarged?

 Is it an LA with a 10 mmHg, 20 mmHg or 30 mmHg pressure

1 – Is the PA>Bronchus in the middle or upper lobe vessels or is there redistribution ?
2- Is there fuzziness to the vessels?
3- Is there alveolar edema?

Impression

LAE and suspect LVEDP between 20-30 mmHg 

Could this be Sarcoid ?

Carinal angle widened could be from adenopathy
Redistribution seems real

Lumpy Bumpy Hila with known adenopathy
CT showed no ILD

Is the LV enlarged?

LVE – > 50% of hemidiaphragm occupied by the LV

Echo showed EF of 50% and apical hypokinesis.
EKG showed ST elevation in V4 and V5.
Mildly elevated Troponins
CT had shown LAD atherosclerotic calcifications

Cath

Elevated troponin necessitated cardiac cath which showed normal coronaries.

LAD identified by the septal arteries coursing toward the diaphragm
SA nodal off the proximal circumflex (60%)
Right dominant system

RAO LAD septal  and diagonals arteries – Normal

 

LAO – Infundibular artery to RVOT,  small anterior RV vessel, acute marginal, PDA and posterior LV branches

LAO – NORMAL RCA

RAO Infundibular (RVOT) , acute marginal, PDA septal vessels and posterior LV branches

Classical Takotsubo Heart

T2 Apical Edema

Mild Apical Hypokinesis and Midventricular Hyperkinesis

LGE

Thus this lady has a diagnosis of sarcoidosis (ocular skin and likely pulmonary)and Takotsubo cardiomyopathy precipitated by an acute emotional stress when the police visited her home looking for men in her basement.

She presented with acute coronary syndrome, ST segment changes on EKG, mildly elevated troponins, CHF on CXR, with normal  coronary arteriography and LV gram characteristic of Takotsubo cardiomyopathy

Next Gene  Kim,