ATTR Cardiac Amyloidosis in a Patient With Pulmonary Sarcoidosis: Not All That Glitters Is Gold

Amyloid transthyretin (ATTR) cardiac amyloidosis is a progressive cardiomyopathy characterized by misfolded transthyretin deposition, resulting in ventricular stiffening which may cause cardiac dysfunction.

An 86-year-old man with history of pulmonary sarcoidosis presented with progressive dyspnea and emesis. An electrocardiogram demonstrated complete heart block and he underwent permanent pacemaker implantation. While initially suspicious for cardiac sarcoidosis, cardiac magnetic resonance imaging and pyrophosphate scan were consistent with ATTR amyloidosis, which was treated with tafamidis.

Sarcoidosis has rarely been found to mimic cardiac amyloidosis in cases of equivocal testing. Pyrophosphate myocardial imaging has been shown to have high sensitivity in the diagnosis of cardiac amyloidosis and may aid in distinguishing pathologies.

While cardiac sarcoidosis should be suspected in patients with known extra-cardiac sarcoidosis who develop cardiac dysfunction or conduction disease, other infiltrative conditions, including amyloidosis, must also be considered. Multimodality imaging has an important role in diagnosis of cardiac amyloidosis.