When Dyspnea Is Not Just Dyspnea Case Editor - Judd FleschReviewed By Clinical Problems AssemblySubmitted byKhadir Kakal, MDFellow, PhysicianUniversity of Southern California, Keck School of MedicineDivision of Pulmonary, Critical Care and Sleep MedicineLos Angeles, CARichard Lubman, MDAssociate Professor of Clinical MedicineUniversity of Southern California, Keck School of MedicineDivision of Pulmonary, Critical Care and Sleep MedicineLos Angeles, CAKamyar Afshar, DOAssistant Professor of Clinical MedicineUniversity of Southern California, Keck School of MedicineDivision of Pulmonary, Critical Care and Sleep MedicineLos Angeles, CASubmit your comments to the author(s). HistoryA 50 year-old man presents to clinic with complaints of dyspnea on exertion of 3-week duration. He denies any significant dyspnea on exertion on a flat surface, but does have some limitations on an incline. He denies any associated cough, hemoptysis, chest pain or orthopnea. He is without any constitutional symptoms.

The patient has been otherwise asymptomatic.  He describes being hospitalized for an episode of pneumonia 13 years ago, but otherwise has no history of asthma, COPD, tuberculosis, coccidioidomycosis or other respiratory diseases.  He has no prior history of cardiac disease.  He was born in Glendora, CA and has lived in the Los Angeles area his entire life.  He has no history of travel-related illness or recent travel.  honeywell air purifier vs ionic proHe is a retired electrician with no known history of exposure to asbestos or other occupational or environmental hazards.  panasonic vs novita air purifierHe is a lifelong non-smoker.air duct cleaning in windsor ontarioPhysical ExamThe patient is in no acute distress.

Vitals are remarkable for bradycardia with a pulse of 40/minute. Otherwise, there is no hypotension or tachypnea. Lungs are clear to auscultation bilaterally without rales, rhonchi or wheezes. Cardiac examination demonstrated sinus bradycardia without murmur, rubs or gallops. The remaining physical examination was unremarkable. An Electrocardiogram was done which showed complete heart block. Chest radiograph was devoid of any pulmonary pathology Normal Left ventricular size with low normal systolic function and no regional wall motion abnormalities. Mild concentric LVH and 2/4 diastolic dysfunction Right ventricle was moderately dilated, with normal systolic function No pericardial effusionLabWBC 4,900 per mm3 Platelets 150,000 per mm3 Lyme Antibody Screen negative ACE level 47 (9-67)Question 1There was a suspicion for cardiac sarcoidosis. Which test is the most sensitive in diagnosing cardiac sarcoidosis?A.Echocardiography B.Endomyocardial Biopsy C.Cardiac MRI D.Electrocardiogram ReferencesMichael C. Iannuzzi, M.D., Benjamin A. Rybicki, Ph.D., and Alvin S. Teirstein, M.D;

N Engl J Med 2007; 357:2153-2165Uemura et al, Histologic diagnostic rate of cardiac sarcoidosis: evaluation of endomyocardial biopsies; Am Heart J. 1999 Aug;138(2 Pt 1):299-302Kim et al, Cardiac Sarcoidosis, Am Heart J 2009;157:9-21Smedma JP, et al. Evaluation of the accuracy of gadolinium-enhanced CMR in the diagnosis of cardiac sarcoidosis. J Am Coll Cardiol 2005;45:1683-1690Roberts WC, McAllister HA Jr., Ferrans VJ, et al. Sarcoidosis of the heart. A clinicopathologic study of 35 necropsy patients (group I) and review of 78 previously described necropsy patients (group II). Am J Med 1977;63:86–108.Youssef et al, CS: applications of imaging in diagnosis and directing treatment. Heart 2011;97:2078-2087Yazaki Y, Isobe M, Hiroe M, et al. Prognostic determinants of long-term survival in Japanese patients with cardiac sarcoidosis treated with prednisone. Am J Cardiol 2001;88:1006-1010 For Sale
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