Exercise-induced torsades de pointes as an unusual presentation of cardiac sarcoidosis: A case report and review of literature

Table 1 Laboratory work-up on presentation

Test	Results	Reference range
Hematology
White blood cells	6.6	4.2-11.4 × 103/mm3
Hemoglobin	12.7	11.8-15.6 g/dL
Hematocrit	40.5	35.3%-46.1%
Platelets	275	174-402 × 103/mm3
Biochemistry
Sodium	140	132-145 mmol/L
Potassium	4.3	3.5-5.1 mmol/L
Magnesium	0.94	0.6-1.1 mmol/L
Calcium	2.27	2.1-2.55 mmol/L
Urea	25	15-50 mg/dL
Creatinine	0.68	0.2-1.2 mg/dL
HbA1c	6.7	4.0%-6.0%
Angiotensin converting enzyme	35	20-70 U/L
Cardiac markers
Creatinine kinase MB	2.8	0.0-5.0 ng/mL
Troponin I (HS)	3	0-15 pg/mL
Cytometry markers
CD4/CD8 ratio	2.78	1.20-2.40
CD3-16+56+ lymphocytes	8.3	5%-15%
CD19 (pan B) lymphocytes	13.40	5%-20%
Thyroid panel
TSH	1.45	0.35-4.95 mU/L
Free T4	1.03	0.70-1.48 ng/dL

HbA1c: Glycated hemoglobin; HS: High sensitivity; MB: Myocardial band; MDRD: Modification of diet in renal disease; TSH: Thyroid stimulating hormone.

Table 2 Summary of the 2017 new guidelines for the diagnosis of cardiac sarcoidosis

Diagnosis of cardiac sarcoidosis follows one of two pathways:
Histological diagnosis
Cardiac biopsy specimens demonstrating noncaseating epithelioid cell granuloma.
Clinical diagnosis
When extracardiac granulomas are found along with clinical findings strongly suggestive of cardiac involvement; or when the patient shows clinical findings strongly suggestive of pulmonary or ophthalmic sarcoidosis; at least two of the five characteristic laboratory findings of sarcoidosis; and clinical findings strongly suggestive of cardiac involvement
Clinical findings that satisfy the following strongly suggest the presence of cardiac involvement:
(1) More than two major criteria are met, OR
(2) One major criterion and two or more minor criteria are met
Major criteria:
Advanced atrioventricular block or malignant ventricular arrhythmia
Basal thinning of the ventricular septum or abnormal wall anatomy
Positive cardiac gallium uptake
Left ventricular contractile dysfunction
LGE on CMR showing delayed contrast enhancement of the myocardium
Minor criteria:
Abnormal ECG findings
Perfusion defects detected by myocardial perfusion scintigraphy
Interstitial fibrosis by endomyocardial biopsy
Laboratory findings
(1) Bilateral hilar lymphadenopathy
(2) High serum angiotensin-converting enzyme level or elevated serum lysozyme levels
(3) High serum soluble interleukin-2 receptor levels
(4) Significant tracer accumulation in 67Ga citrate scintigraphy or 18F-FDG PET
(5) A CD4/CD8 ratio of > 3.5 in broncho-alveolar lavage fluid

CMR: Cardiovascular magnetic resonance; ECG: Electrocardiogram; FDG: Fluorodeoxyglucose; LGE: Late gadolinium enhancement; PET: Positron emission tomography.