Cardiac sarcoidosis with a twist - active and fibrotic sarcoid with antiphospholipid positivity: A case report

Table 1 Case outline

Timeline	Events
Day 1	A 54-year-old male with non-ischemic heart failure with reduced ejection fraction, interstitial lung disease, pulmonary hypertension, and chronic marijuana presents with recurrent palpitations and dyspnea. Telemetry shows a high burden of PVCs and NSVT. Chest X-ray and computed tomography demonstrate lung nodules with fibrosis
Day 4	Bronchial ultrasound and alveolar lavage confirm pulmonary sarcoidosis. Escalation of rate control therapy fails to resolve PVCs and NSVTs
Day 6	Initiation of rhythm control therapy decreases and eventually resolves arrhythmias. Cardiac magnetic resonance imaging showed left ventricular dilation with severe systolic dysfunction, global hypokinesis, and patchy uptake
Day 9	Positron emission tomography has system FDG but no cardiac FDG, confirming active systemic sarcoidosis (SS) and burnt CS. ACL and B2M antibodies are positive, raising concern for APP and antiphospholipid syndrome. Medical and device therapy are begun for burnt CS and prednisone for SS
Day 16	MTX is begun with plan for taper up and prednisone for taper down
Day 166	Repeat ACL and B2M antibodies are positive in the absence of thromboembolic events. APP is confirmed; aspirin therapy is begun and prednisone taper is accelerated
Day 280	Transition to MTX is complete and prednisone discontinued
Day 360	Follow up imaging demonstrates resolution of arrhythmias and pulmonary disease; no thromboembolic phenomena are observed

HFrEF: Heart failure with reduced ejection fraction; PVCs: Premature ventricular complexes; NSVT: Non-sustained ventricular tachycardia; FDG: Fluorodeoxyglucose; CS: Cardiac sarcoidosis; ACL: Anticardiolipin; B2M: Beta-2-microglobulin; APP: Antiphospholipid positivity; MTX: Methotrexate.