Sarcoidosis with Cardiac Involvement

Description of Clinical Presentation: A 65-year-old female, with a history of smoking and hypertension, underwent a screening breast ultrasound in October 2023, which revealed non-specific bilateral axillary adenopathy. Clinically, the patient's sole presenting symptom was intractable myalgia in multiple sites.
Due to the persistence of adenopathies on a follow-up ultrasound, an FDG PET-CT was requested.

Diagnostic Techniques and Their Most Important Findings: FDG PET-CT Findings:

This study revealed multiple hypermetabolic supra- and infradiaphragmatic adenopathies, with a predominance in the mediastinum and pulmonary hila, along with lung nodules with a perilymphatic distribution, predominantly peribronchovascular. Notably, there were patchy areas of myocardial FDG uptake in non-vascular distribution. Additionally, multifocal hypermetabolic muscular involvement was found.
Additionally, a 2022 abdominal CT with contrast was retrospectively evaluated. The visible thoracic sections incidentally revealed conspicuous pre-existing hypodense areas of myocardial infiltration.
Based on these findings, sarcoidosis was considered the most likely etiology.

Due to patient preference, an EBUS-guided mediastinal biopsy was subsequently performed one year later, in December 2024, confirming the diagnosis of sarcoidosis.

CMR Findings:

The patient subsequently presented with atypical chest pain, for which a cardiac MRI was performed in February 2025, on a 1.5 Tesla scanner (Magnetom Aera, Siemens Healthcare).
The study demonstrated patchy areas of mesocardial and transmural late gadolinium enhancement with a non-vascular distribution. Furthermore, evidence of apical anterolateral wall thinning with focal aneurysmal dilatation and dyskinesia was noted.

CTA:

Thereafter, a Computed Tomography Angiography (CTA) was performed. The study revealed non-obstructive coronary artery disease with a moderate total plaque burden (CAD-RADS 2 / P2).
The findings of this study support the diagnosis of a non-ischemic cardiomyopathy.

Learning Points from this Case: The presented case documents the temporal evolution of cardiac sarcoidosis, as characterized by a multi-modality imaging approach.

Cardiac involvement in sarcoidosis can be characterized by various complementary imaging modalities, particularly highlighting the roles of Cardiac Magnetic Resonance (CMR) and FDG PET-CT.

For an accurate diagnosis, it's essential to consider the myocardial distribution of the granulomatous infiltrative process. This corresponds to a non-ischemic pattern, primarily affecting the mid-myocardial or epicardial layers in the basal and mid-ventricular segments of the left ventricle.

On PET-CT: In active disease, the affected areas present with hypermetabolism.

On Cardiac Magnetic Resonance: Late Gadolinium Enhancement (LGE) allows for the identification of scarring or fibrosis. T1 and T2 mapping are especially useful in the early stages of the disease when LGE is not yet visible, as they can detect subtle changes in tissue composition.

FDG PET-CT: Multiple hypermetabolic supra- and infradiaphragmatic adenopathies. Patchy areas of myocardial FDG uptake in non-vascular distribution.
CMR: Patchy areas of mesocardial and transmural late gadolinium enhancement
2022: Incidental pre-existing hypodense areas of myocardial infiltration. 2025: Apical anterolateral wall thinning.