A Fatal Case of Cardiac Sarcoidosis Presenting as Refractory Ascites

Sarcoidosis is a multisystem granulomatous disease with variable clinical presentations, most commonly affecting the lungs. Cardiac sarcoidosis (CS), though rare, is a serious complication that can lead to restrictive cardiomyopathy and carries a poor prognosis. We report the case of a 44-year-old male patient who presented with worsening ascites, fatigue, orthopnea, and peripheral edema. Initial workup revealed transudative ascites and new-onset severe heart failure, with echocardiography showing an ejection fraction of 15%-20%, bi-atrial enlargement, left ventricular hypertrophy, and grade 3 diastolic dysfunction. Cardiac catheterization confirmed non-ischemic cardiomyopathy. Imaging showed pulmonary and mediastinal lymphadenopathy and ground-glass opacities. Due to the patient's instability, a biopsy was deferred, and a myocardial fluorodeoxyglucose-18 positron emission tomography (FDG-PET) scan was performed, demonstrating diffuse hypermetabolic activity consistent with active CS. Despite immunosuppressive therapy with prednisone, methotrexate, hydroxychloroquine, and folate, the patient deteriorated and succumbed to fatal arrhythmias and advanced conduction abnormalities. This case highlights the diagnostic utility of FDG-PET in unstable patients and underscores the importance of considering CS in patients with unexplained heart failure and transudative ascites. Early recognition and consideration for cardiac transplant are critical in improving outcomes.