Like a House Afire: Cardiac Sarcoidosis 

It seemed like an obvious case of acute coronary syndrome—but was it really? A 36-year-old man of Sri Lankan origin presented to his local rural emergency department with severe central chest pain. He described persistent chest tightness radiating to his left arm. This had developed at rest and was unaffected by inspiration or posture. Over the preceding 24 hours, he had several short-lived episodes of similar but milder pain that resolved spontaneously. Otherwise, the patient had been well with no recent viral illness. His medical history was significant for diet-controlled type 2 diabetes mellitus and hypercholesterolemia. He was a smoker and had a strong family history of premature coronary artery disease.

On examination, the patient was hemodynamically stable. His heart sounds were normal, with no pericardial rub, and his lungs were clear on auscultation. An electrocardiogram (ECG) showed sinus rhythm with 1-mm ST elevation in leads I and aVL. A chest radiograph showed normal cardiac and mediastinal contours with clear lung fields. Serum troponin T at admission was significantly elevated at 4.3 μg/L (normal < 0.02).

A random blood glucose measurement was 14.1 mmol/L, and hemoglobin A1c was raised at 9.2%. The patient’s white cell count was mildly elevated at 1.36 x103/mm3, and his C-reactive protein level was 23 mmol/L. A diagnosis of acute coronary syndrome was made. Treatment was initiated with aspirin and clopidogrel after a loading dose of clopidogrel, 300 mg. He also received a therapeutic dose of subcutaneous low-molecular-weight heparin and opiate analgesia. He was not given thrombolysis, and no catheterization laboratory facilities were available at this rural location.

Over the next 24 hours, the patient had ongoing pain requiring opiate analgesia. To read this article in its entirety, please visit our website.

— James D. Richardson, MBBS, Michael S. Cunnington, MBBS, Adam J. Nelson, MBBS, Julie A. Bradley, PhD, Karen S.L. Teo, PhD, Stephen G. Worthley, PhD, Matthew I. Worthley, PhD

This article originally appeared in the January 2013 issue of The American Journal of Medicine.