Systemic Sarcoidosis With Cardiac Involvement: Pyrexia With Revived Cardiac Arrest

A 50-year-old female presented with complaints of intermittent fever during the evening hours for three weeks, associated with decreased appetite and generalized weakness. Clinical examination revealed an erythematous rash over both lower limbs and scleral congestion in the eyes. She was admitted to the general ward for further evaluation. On day 1 of admission, she developed an episode of ventricular fibrillation, which was reverted with cardioversion. She had no past or family history of heart disease. She was intubated during cardiopulmonary resuscitation, placed on mechanical ventilatory support, and subsequently transferred for further management. Post-arrest imaging was performed. Echocardiography showed no regional wall motion abnormality and a normal ejection fraction. Chest radiography revealed bilateral hilar prominence, while CT of the chest demonstrated enlarged lymph nodes in the pre-carinal, pre-tracheal, and subcarinal regions. Blood, urine, and endotracheal secretion cultures were sterile. Laboratory investigations revealed an elevated erythrocyte sedimentation rate, anemia (hemoglobin: 10.8 g/dL), acute kidney injury (serum creatinine: 2.3 mg/dL), and hypercalcemia (12.6 mg/dL). Tracheal secretions were negative for tuberculosis polymerase chain reaction, and no acid-fast bacilli or fungal elements were seen on staining. The angiotensin-converting enzyme (ACE) level was elevated (141.9 U/L). The history of prolonged fever, elevated inflammatory markers, anemia, acute kidney injury, hypercalcemia, bilateral hilar prominence, mediastinal lymphadenopathy, and raised ACE levels prompted consideration of sarcoidosis. Cardiac MRI demonstrated late gadolinium enhancement, suggestive of infiltrative disease. Serum protein electrophoresis was negative for M bands. A skin biopsy taken from the erythematous rash on the lower limb, a cutaneous manifestation of sarcoidosis, revealed non-caseating granulomas. She was diagnosed with systemic sarcoidosis with cardiac involvement. Treatment was initiated with corticosteroids, followed by the addition of a steroid-sparing agent. This case highlights the clinical features, diagnostic workup, and management of a rare presentation of cardiac sarcoidosis.