8/4/2019 Cardiac Sarcoid

1/7

DOI 10.1378/chest.107.2.3301995;107;330-334Chest

Wakabayashi, Kingo Chida and Atsuhiko SatoKenichi Okayama, Chinori Kurata, Kei Tawarahara, Yasushiand Gallium-67 in Cardiac Sarcoidosis

Thallium-201Myocardial Scintigraphy WithDiagnostic and Prognostic Value of

http://chestjournal.chestpubs.org/content/107/2/330

services can be found online on the World Wide Web at:The online version of this article, along with updated information and

ISSN:0012-3692)http://chestjournal.chestpubs.org/site/misc/reprints.xhtml(

prior written permission of the copyright holder.of this article or PDF may be reproduced or distributed without theDundee Road, Northbrook, IL 60062. All rights reserved. No partCopyright1995by the American College of Chest Physicians, 3300Physicians. It has been published monthly since 1935.

is the official journal of the American College of ChestChest

1995, by the American College of Chest Physiciansat Ohio State University on March 4, 2011chestjournal.chestpubs.orgDownloaded from

http://chestjournal.chestpubs.org/content/107/2/330http://chestjournal.chestpubs.org/content/107/2/330http://chestjournal.chestpubs.org/content/107/2/330http://chestjournal.chestpubs.org/site/misc/reprints.xhtmlhttp://chestjournal.chestpubs.org/site/misc/reprints.xhtmlhttp://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/site/misc/reprints.xhtmlhttp://chestjournal.chestpubs.org/content/107/2/330

8/4/2019 Cardiac Sarcoid

2/7

D i a g n o s t i c a n d P r o g n o s t i c V a l u e o fM y o c a r d i a l S c i n t i g r a p h y W i t h T h a l l i u m -2 0 1 a n d G a l l i u m - 6 7 i n C a r d i a cS a r c o i d o s i s *K e n i c h i O k a y a m a , MD; C h i n o r i K u r a t a , MD; K e i T a w a r a h a r a , MD;Y a s u s h i W a k a b a y a s h i , MD; K i n g o C h i d a , MD;a n d A t s u h i k o S a t o , MD, FCCPS t u d y o b j e c t i v e : T o e x a m i n e t h e d i a g n o s t i c a n d p r o g -n o s t i c v a l u e o f m y o c a r d i a l s c i n t i g r a p h y u s i n g t h a l l i u m -2 0 1 a n d g a l l i u m - 6 7 i n c a r d i a c s a r c o i d o s i s .P a t i e n t s : T w e n t y - f i v e p a t i e n t s w i t h s a r c o i d o s i s .M e t h o d s : A l l p a t i e n t s u n d e r w e n t m y o c a r d i a l t h a l l i u m -2 0 1 s c i n t i g r a p h y . S i x p a t i e n t s w i t h m y o c a r d i a l t h a l l i u m -2 0 1 d e f e c t s w e r e c l a s s i f i e d i n t o g r o u p A a n d a n o t h e r 1 9w i t h o u t d e f e c t s w e r e c l a s s i f i e d i n t o g r o u p B . B e t w e e ng r o u p A a n d B , we c o m p a r e d t h e r e s u l t s o f o t h e r n o n i n -v a s i v e e x a m i n a t i o n s , i n c l u d i n g s t a n d a r d 1 2 - l e a d E C G ,2 4 h a m b u l a t o r y E C G , c h e s t r a d i o g r a p h y , m e a s u r e -m e n t s o f s e r u m a n g i o t e n s i n - c o n v e r t i n g e n z y m e ( A C E )a n d l y s o z y m e l e v e l s , a n d g a l l i u m - 6 7 s c i n t i g r a p h y .R e s u l t s : P r o p o r t i o n s o f s u b j e c t s who h a d v a r y i n g d e -g r e e s o f h e a r t b l o c k , s e v e r e v e n t r i c u l a r a r r h y t h m i a s( m o r e t h a n o r e q u a l t o t h i r d g r a d e o f L o w n ' s c l a s s i f i c a -t i o n ) , a n d h i g h l e v e l s o f s e r u m ACE a n d l y s o z y m e l e v -e l s w e r e n o t d i f f e r e n t b e t w e e n t h e s e t w o g r o u p s ( p > 0 . 0 5 ) .A l t h o u g h a n e n l a r g e d c a r d i o t h o r a c i c r a t i o w a s m o r ef r e q u e n t i n g r o u p A ( p < 0 . 0 5 ) , b i l a t e r a l h i l a r l y m p h a d e -n o p a t h y w a s m o r e f r e q u e n t i n g r o u p B ( p < 0 . 0 1 ) . F o u rp a t i e n t s o f g r o u p A a n d 1 5 o f g r o u p B u n d e r w e n t g a l l i -u m - 6 7 s c i n t i g r a p h y . A l t h o u g h n o s u b j e c t s o f g r o u p B h a dS a r c o i d o s i s i s a m u l t i s y s t e m d i s o r d e r o f u n k n o w ne t i o l o g y . A l t h o u g h t h e o r g a n m o s t f r e q u e n t l y a f -f e c t e d i s t h e l u n g , a l l p a r t s o f t h e b o d y c a n b ea f f e c t e d . O v e r a l l t h e p r o g n o s i s i s g o o d b e c a u s e o r g a ni n v o l v e m e n t i s u s u a l l y a s y m p t o m a t i c a n d t h e d i s e a s ei s o f t e n s e l f - l i m i t i n g . " 1 2 C a r d i a c s a r c o i d o s i s , h o w e v e r ,s o m e t i m e s c a u s e s f a t a l v e n t r i c u l a r t a c h y a r r h y t h m i a so r c o n d u c t i o n b l o c k , 3 ' 4 a n d r e t r o s p e c t i v e s t u d i e s h a v er e v e a l e d m y o c a r d i a l i n v o l v e m e n t i n a p p r o x i m a t e l y2 5 % o f t h e s e p a t i e n t s . 5 D i a g n o s i s o f m y o c a r d i a li n v o l v e m e n t o f s a r c o i d o s i s d u r i n g l i f e i s d i f f i c u l t b e -c a u s e c l i n i c a l e v i d e n c e o f m y o c a r d i a l i n v o l v e m e n t i sa p p a r e n t i n o n l y 5 % o f t h e p a t i e n t s . 3 ' 4 ' 5 I t i s p a r t i c -u l a r l y r e q u i r e d t o d i a g n o s e c a r d i a c s a r c o i d o s i s w i t h i na n a s y m p t o m a t i c s t a g e b e c a u s e s u d d e n d e a t h i s t h em o s t common m a n i f e s t a t i o n o f t h i s d i s e a s e . 4 ' 6 E n d o -m y o c a r d i a l b i o p s y m a y b e e s s e n t i a l f o r e s t a b l i s h i n g* F r o m t h e T h i r d a n d S e c o n d D e p a r t m e n t s o f I n t e r n a l M e d i c i n e ,Hamamatsu U n i v e r s i t y S c h o o l o f M e d i c i n e , H a m a m a t s u , J a p a n .M a n u s c r i p t r e c e i v e d A p r i l 2 9 , 1 9 9 4 ; r e v i s i o n a c c e p t e d J u n e 8 .R e p r i n t r e q u e s t s : D r . O k a y a m a , T h i r d D e p t . o f I n t e r n a l M e d i -c i n e , Ham am atsu U n i v e r s i t y , 3 6 0 0 H a n d a - C h o , H a m a m a t s u ,4 3 1 - 3 1 J a p a n3 3 0

m y o c a r d i a l u p t a k e o f g a l l i u m - 6 7 , t w o o f f o u r g r o u p Ap a t i e n t s s h o w e d c a r d i a c u p t a k e . T h e s e f o u r g r o u p Ap a t i e n t s w e r e t r e a t e d w i t h c o r t i c o s t e r o i d s . T h e t h e r a p yp r o v i d e d c l i n i c a l a n d s c i n t i g r a p h i c i m p r o v e m e n t i n twop a t i e n t s w i t h m y o c a r d i a l g a l l i u m - 6 7 u p t a k e , a l t h o u g h i td i d n o i m p r o v e m e n t i n t h e o t h e r t w o p a t i e n t s w i t h o u tg a l l i u m - 6 7 u p t a k e .C o n c l u s i o n s : When c a r d i a c s a r c o i d o s i s w a s d i a g n o s e da c c o r d i n g t o m y o c a r d i a l t h a l l i u m - 2 0 1 d e f e c t s , o t h e rn o n i n v a s i v e e x a m i n a t i o n s w e r e n o t u s e f u l t o d e t e c t t h i sd i s e a s e . H o w e v e r , g a l l i u m - 6 7 u p t a k e m a y p r e d i c t t h ee f f i c a c y o f c o r t i c o s t e r o i d s . T h u s , t h e c o m b i n a t i o n o ft h a l l i u m - 2 0 1 a n d g a l l i u m - 6 7 s c i n t i g r a p h y m a y b e u s e f u ln o t o n l y i n d i a g n o s i s o f c a r d i a c s a r c o i d o s i s b u t a l s o i np r e d i c t i o n o f e f f e c t s o f c o r t i c o s t e r o i d s .( C h e s t 1 9 9 5 ; 1 0 7 : 3 3 0 - 3 4 )

A C E = a n g i o t e n s i n - c o n v e r t i n g e n z y m e ; B H L = b i l a t e r a l h i -l a r l y m p h a d e n o p a t h y ; C T R = c a r d i o t h o r a c i c r a t i oK e y w o r d s : c a r d i a c s a r c o i d o s i s ; g a l l i u m - 6 7 ; m y o c a r d i a ls c i n t i g r a p h y ; t h a l l i u m - 2 0 1t h e d i a g n o s i s o f c a r d i a c s a r c o i d o s i s . H o w e v e r , i t i si n v a s i v e a n d may l a c k s e n s i t i v i t y b e c a u s e m y o c a r d i a li n v o l v e m e n t i s n o t h o m o g e n e o u s . N e g a t i v e b i o p s yf i n d i n g s t h e r e f o r e d o n o t e x c l u d e c a r d i a c s a r c o i d o s i s ,a l t h o u g h a b n o r m a l f i n d i n g s a r e d i a g n o s t i c . 3 ' 4 ' 7M y o c a r d i a l s c i n t i g r a p h y w i t h t h a l l i u m - 2 0 1 h a sb e e n u s e d i n p a t i e n t s w i t h s u s p e c t e d c a r d i a c s a r c o i -d o s i s . 3 ' 4 ' 8 ' 9 S e g m e n t a l a r e a s w i t h t h a l l i u m - 2 0 1 d e f e c t sc o r r e s p o n d t o a r e a s o f f i b r o g r a n u l o m a t o u s r e p l a c e -m e n t . 6 G a l l i u m - 6 7 i m a g i n g a l s o h a s b e e n u s e d t od e t e c t o r g a n i n v o l v e m e n t s , i n c l u d i n g m y o c a r d i -u m . 1 ' 1 0 I t s u p t a k e s u g g e s t s m y o c a r d i a l i n f i l t r a t i o n b ys a r c o i d o s i s . T h e c o m b i n a t i o n o f t h a l l i u m - 2 0 1 a n dg a l l i u m - 6 7 m y o c a r d i a l s c i n t i g r a p h y may p r o v i d em o r e i n f o r m a t i o n a b o u t m y o c a r d i a l i n v o l v e m e n t o fs a r c o i d o s i s . 1 1 " 2M y o c a r d i a l i n v o l v e m e n t a p p e a r s t o b e a n i n d i c a -t i o n f o r c o r t i c o s t e r o i d h o r m o n e t h e r a p y , r e g a r d l e s s o ft h e s e v e r i t y o f t h e s y s t e m i c d i s e a s e . 3 E f f e c t o f t h i st h e r a p y , h o w e v e r , v a r i e s f r o m e x c e l l e n t t o p o o r . A c -c u m u l a t i o n o f g a l l i u m - 6 7 i s c o n s i d e r e d a s a n i n d i c a -t o r o f i n f l a m m a t o r y c h a n g e . A l a r g e d o s e o f c o r t i -

M y o c a r d i a l S c i n t i g r a p h y W i t h T I - 2 0 1 a n d G a - 6 7 i n S a r c o i d o s i s ( O k a y a m a e t a l )1995, by the American College of Chest Physicians

at Ohio State University on March 4, 2011chestjournal.chestpubs.orgDownloaded from

http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/

8/4/2019 Cardiac Sarcoid

3/7

c o s t e r o i d s i s a p p r o v e d t o d e c r e a s e t h e a c c u m u l a t i o no f g a l l i u m - 6 7 i n p a t i e n t s w i t h p u l m o n a r y s a r c o i d o -s i s . 1 0 P a t i e n t s w i t h m y o c a r d i a l g a l l i u m - 6 7 u p t a k em a y t h e r e f o r e b e r e s p o n s i v e t o c o r t i c o s t e r o i d t h e r -a p y . I n t h i s s t u d y , w e e x a m i n e d w h e t h e r m y o c a r d i a lt h a l l i u m - 2 0 1 s c i n t i g r a p h y c a n p l a y a s i g n i f i c a n t r o l ei n d e p e n d e n t l y o f o t h e r n o n i n v a s i v e e x a m i n a t i o n s i nt h e d i a g n o s i s o f m y o c a r d i a l s a r c o i d o s i s a n d w h e t h e rg a l l i u m - 6 7 s c i n t i g r a p h y c a n p r e d i c t t h e e f f e c t o fc o r t i c o s t e r o i d s o n m y o c a r d i a l s a r c o i d o s i s .

METHODSA p a t i e n t p o p u l a t i o n c o n s i s t e d o f 2 5 p a t i e n t s w h o u n d e r w e n tt h a l l i u m - 2 0 1 s c i n t i g r a p h y i n o u r h o s p i t a l b e t w e e n 1 9 8 8 a n d 1 9 9 2 .S a r c o i d o s i s w a s d i a g n o s e d b y p u l m o n o l o g i s t s i n a l l p a t i e n t s e x c e p t

o n e w h o s e c o n d i t i o n w a s d i a g n o s e d b y d e r m a t o l o g i s t s o n s k i n b i -o p s y s p e c i m e n . A l l t h e p a t i e n t s h a d n o h i s t o r y o f i s c h e m i c h e a r td i s e a s e a n d n o e v i d e n c e o f p r e v i o u s m y o c a r d i a l i n f a r c t i o n o nr e s t i n g E C G . M y o c a r d i a l t h a l l i u m - 2 0 1 s c i n t i g r a p h y w a s p e r -f o r m e d i n a l l p a t i e n t s . A f t e r a n o v e r n i g h t f a s t , 1 1 1 MB q o f t h a l -l i u m - 2 0 1 w a s i n j e c t e d i n t r a v e n o u s l y i n a n u p r i g h t p o s i t i o n a n ds i n g l e p h o t o n e m i s s i o n c o m p u t e d t o m o g r a p h y w a s b e g u n 5 m i nl a t e r . T h e t o m o g r a p h i c i m a g e s o f v e r t i c a l l o n g a x i s , h o r i z o n t a ll o n g a x i s , a n d s h o r t a x i s w e r e r e c o n s t r u c t e d . S e g m e n t a l u p t a k e sw e r e g r a de d v i s u a l l y a s f o l l o w s : g r a d e 0 , s e v e r e l y r e d u c e d ; g r a d e1 , m o d e r a t e l y r e d u c e d ; g r a d e 2 , m i l d l y r e d u c e d ; a n d g r a d e 3 ,i n t a c t u p t a k e . W e r e g a r d e d t h e u p t a k e l e s s t h a n o r e q u a l t o g r a d e2 a s a n a b n o r m a l m y o c a r d i a l d e f e c t . A l l p a t i e n t s w i t h m y o c a r d i a ld e f e c t s o n t h a l l i u m - 2 0 1 s c i n t i g r a p h y u n d e r w e n t c o r o n a r y a n -g i o g r a p h y a n d s h o w e d n o r m a l c o r o n a r y a r t e r i e s .N o n i n v a s i v e e x a m i n a t i o n s , i n c l u d i n g c h e s t r a d i o g r a p h y , E C G ,a m b u l a t o r y E C G , a n d m e a s u r e m e n t s o f s e r u m a n g i o t e n s i n - c o n -v e r t i n g e n z y m e ( A C E ) a n d l y s o zy m e l e v e l s w e r e e v a l u a t e d . M y -o c a r d i a l i m a g i n g w i t h 1 1 1 MB q o f g a l l i u m - 6 7 w a s p e r f o r m e d i n2 1 p a t i e n t s . I f m y o c a r d i a l g a l l i u m - 6 7 u p t a k e w a s f o u n d o n p l a -n a r i m a g e , m y o c a r d i a l s i n g l e p h o t o n e m i s s i o n c o m p u t e d t o m o g -r a p h y w a s p e r f o r m e d .T w e n t y - f i v e p a t i e n t s w e r e c l a s s i f i e d i n t o t w o g r o u p s a c c o r d i n gt o t h e p r e s e n c e o r a b s e n c e o f d e f e c t s o f m y o c a r d i a l t h a l l i u m - 2 0 1s c i n t i g r a p h y . S i x p a t i e n t s s h o w e d t h a l l i u m - 2 0 1 d e f e c t s ( g r o u p A )a n d t h e o t h e r 1 9 s h o w e d n o d e f e c t s ( g r o u p B ) . B e t w e e n g r o u p Aa n d B , we c o m p a r e d t h e f r e q u e n c i e s o f e n l a r g e d c a r d i o t h o r a c i cr a t i o ( C T R ) ( > 5 0 % ) o r b i l a t e r a l h i l a r l y m p h a d e n o p a t h y ( B H L ) o nc h e s t r a d i o g r a p h s , a n y k i n d o f v e n t r i c u l a r a r r h y t h m i a s a n dv a r y i n g d e g r e e o f h e a r t b l o c k o n E C G , s e v e r e v e n t r i c u l a ra r r h y t h m i a s m o r e t h a n o r e q u a l t o t h i r d g r a d e o f L o w n ' s c l a s s i -f i c a t i o n o n a m b u l a t o r y E C G , m y o c a r d i a l g a l l i u m - 6 7 u p t a k e , a n ds e r u m ACE a n d l y s o z y m e l e v e l s .F o u r p a t i e n t s o f g r o u p A w e r e t r e a t e d w i t h p r e d n i s o l o n e , 5 0 t o6 0 m g / d f o l l o w e d b y g r a d u a l t a p e r i n g t o a m a i n t e n a n c e d o s e o f2 0 t o 3 0 mg e v e r y o t h e r d a y . T h r e e o r f o u r m o n t h s l a t e r , t h e y h a dm y o c a r d i a l s c i n t i g r a p h y w i t h t h a l l i u m - 2 0 1 a n d g a l l i u m - 6 7 a g a i n .T h e p r o c e d u r e w a s e x a c t l y a s f o r t h e e a r l i e r s t u d i e s . D i f f e r e n c e sb e t w e e n t h e s e t w o g r o u p s w e r e e x a m i n e d b y S t u d e n t ' s t t e s t o r x 2t e s t . T h e ACE a n d l y s o z y m e l e v e l s w e r e e x p r e s s e d a s m e a n s t a n d a r d d e v i a t i o n .

R E S U L T SA s u m m a r y o f t h e c l i n i c a l f i n d i n g s i s p r e s e n t e d i nT a b l e s 1 a n d 2 . T h e p r o p o r t i o n s o f t h e p a t i e n t s w i t ha n y k i n d o f a b n o r m a l i t i e s o n ECG a n d a m b u l a t o r yE C g , a n d m e a n l e v e l s o f s e r u m ACE a n d l y s o z y m ew e r e n o t s i g n i f i c a n t l y d i f f e r e n t b e t w e e n t w o g r o u p s

( p > 0 . 0 5 ) . T h e p r o p o r t i o n o f t h e p a t i e n t s w i t h a n e n -l a r g e d CTR o n c h e s t r a d i o g r a p h s w a s s i g n i f i c a n t l yh i g h e r i n g r o u p A t h a n i n g r o u p B ( p < 0 . 0 5 ) . C o n -v e r s e l y , t h e p r o p o r t i o n o f B H L w a s s i g n i f i c a n t l yl o w e r i n g r o u p A t h a n i n g r o u p B ( p < 0 . 0 1 ) ( T a b l e 3 ) .Two p a t i e n t s o f g r o u p A h a d a b n o r m a l g a l l i u m - 6 7u p t a k e s i n t h e h e a r t . On t o m o g r a p h i c i m a g i n g , t h em y o c a r d i a l r e g i o n s w i t h g a l l i u m - 6 7 u p t a k e c o r r e -s p o n d e d t o t h o s e w i t h t h a l l i u m - 2 0 1 d e f e c t s . F o u r o fs i x p a t i e n t s o f g r o u p A w e r e t r e a t e d w i t h c o r t i c o s -t e r o i d s . Two p a t i e n t s w i t h m y o c a r d i a l g a l l i u m - 6 7u p t a k e s s h o w e d e x c e l l e n t c l i n i c a l i m p r o v e m e n t a s -s o c i a t e d w i t h d i s a p p e a r a n c e o f m y o c a r d i a l g a l l i -u m - 6 7 u p t a k e s a n d r e d u c t i o n o f t h a l l i u m - 2 0 1 d e -f e c t s . T h e o t h e r t w o p a t i e n t s w i t h o u t m y o c a r d i a lg a l l i u m - 6 7 u p t a k e d i d n o t s h o w a n y i m p r o v e m e n td e s p i t e h i g h - d o s e c o r t i c o s t e r o i d t h e r a p y ( T a b l e 4 ) .D I S C U S S I O N

I n t h i s s t u d y , w h e n c a r d i a c i n v o l v e m e n t s o f s a r -c o i d o s i s w e r e d i a g n o s e d a c c o r d i n g t o t h e f i n d i n g s o fm y o c a r d i a l t h a l l i u m - 2 0 1 s c i n t i g r a p h y , o t h e r f i n d i n g so f n o n i n v a s i v e e x a m i n a t i o n s , i n c l u d i n g B H L , a n yk i n d o f c o n d u c t i o n b l o c k , v e n t r i c u l a r a r r h y t h m i a s ,a n d s e r u m ACE a n d l y s o z y m e l e v e l s w e r e n o t u s e f u lf o r d e t e c t i n g c a r d i a c s a r c o i d o s i s . A l t h o u g h t h e f r e -

T a bP a t i e n t /A g e , y r /

S e xG r o u p A

1 / 8 0 / F2 / 7 1 / F3 / 6 6 / F4 / 5 8 / F5 / 6 5 / F6 / 3 4 / FG r o u p B7 / 7 1 / F8 / 7 1 / F9 / 5 6 / F1 0 / 6 9 / M1 1 / 4 5 / M

1 2 / 3 0 / F1 3 / 5 3 / F1 4 / 3 4 / M1 5 / 5 1 / F1 6 / 3 7 / F1 7 / 4 2 / M1 8 / 2 9 / F1 9 / 4 2 / M2 0 / 5 2 / M2 1 / 3 0 / M2 2 / 6 9 / F2 3 / 5 8 / F2 4 / 2 8 / M2 5 / 3 6 / M

* N P = n o t p e r f o r m e d .

l e 1 - P a t i e n t D a t a ( 1 )M y o c a r d i a lD e f e c t s o fT h a l l i u m - 2 0 1

P a t c h yP a t c h yP a t c h yA n t e r i o rP a t c h yA n t e r i o r

M y o c a r d i a lU p t a k e s o fG a l l i u m - 6 7

P a t c h yA n t e r i o r

NP*

N PN P

N P

CHEST / 1 0 7 / 2 / F E B R U A R Y , 1 9 9 5 3 3 11995, by the American College of Chest Physicians

at Ohio State University on March 4, 2011chestjournal.chestpubs.orgDownloaded from

http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/

8/4/2019 Cardiac Sarcoid

4/7

T a b l e 2 - P a t i e n t D a t a ( 2 ) *P a t i e n t C T R , % B H L ECG L o w n ' s G r a d e A C E , I U / L L y s o z y m e , , u g / LG r o u p A1 5 8 - N o r m a l 1 1 4 . 6 9 . 0

2 7 2 - N o r m a l 2 2 0 . 5 1 3 . 63 5 6 - N o r m a l 4 1 8 . 1 1 4 . 94

8/4/2019 Cardiac Sarcoid

5/7

T a b l e 4 - E f f e c t s o f C o r t i c o s t e r o i d sB e f o r e S t e r o i d T h e r a p y A f t e r S t e r o i d T h e r a p y

M y o c a r d i a l D e f e c t s M y o c a r d i a l U p t a k e s M y o c a r d i a l D e f e c t s M y o c a r d i a l U p t a k e s C l i n i c a lP a t i e n t o f T h a l l i u m - 2 0 1 o f G a l l i u m - 6 7 o f T h a l l i u m - 2 0 1 o f G a l l i u m - 6 7 C o u r s eG r o u p A

3 + + R e d u c e d D i s a p p e a r e d I m p r o v e d4 + + R e d u c e d D i s a p p e a r e d I m p r o v e d5 + - No c h a n g e D e a d6 + - No c h a n g e N o c h a n g e

s e n t e d i n a p r e v i o u s r e p o r t . 1 4 F u r t h e r s t u d i e s a r en e e d e d t o e x a m i n e t h i s t e n d e n c y f o r t h e f r e q u e n c yo f B H L t o b e d e c r e a s e d i n p a t i e n t s w i t h c a r d i a c s a r -c o i d o s i s .A s m a n y a s 5 0 % o f p a t i e n t s w i t h c a r d i a c s a r c o i d o -s i s h a v e ECG a b n o r m a l i t i e s o f r h y t h m , c o n d u c t i o n ,a n d r e p o l a r i z a t i o n . 3 4 T h e s e a b n o r m a l i t i e s c o m m o n l yo c c u r w i t h o u t c a r d i a c s y m p t o m s . 3 I n o u r s t u d y , t h ef r e q u e n c y o f p a t i e n t s w i t h a n y k i n d o f c o n d u c t i o nb l o c k o r v e n t r i c u l a r a r r h y t h m i a s w a s n o t s i g n i f i -c a n t l y d i f f e r e n t b e t w e e n t w o g r o u p s . S t a n d a r d ECGm a y f a i l t o d e t e c t t h e s e a b n o r m a l i t i e s b e c a u s e a r -r h y t h m i a s a r e o f t e n p a r o x y s m a l a n d c o n d u c t i o n a b -n o r m a l i t i e s m a y v a r y . A l t h o u g h s e r i a l ECG mays h o w v a r y i n g c o n d u c t i o n a b n o r m a l i t i e s , i t i s s t i l ld i f f i c u l t t o d e t e c t p a r o x y s m a l a r r h y t h m i a s . I f we d i -a g n o s e d c a r d i a c s a r c o i d o s i s o n t h e b a s i s o f E C G , 2g r o u p A p a t i e n t s m i g h t b e r e g a r d e d a s a b n o r m a l( s e n s i t i v i t y : 3 3 % ) a n d 1 4 g r o u p B p a t i e n t s m i g h t b er e g a r d e d a s n o r m a l ( s p e c i f i c i t y : 7 1 % ) . T h e s e n s i t i v i t yi s t o o l o w t o d e t e c t c a r d i a c s a r c o i d o s i s . F u r t h e r m o r e ,i t i s d e s i r a b l e t o d e t e c t t h i s d i s e a s e b e f o r e a p p e a r a n c eo f t h e s e ECG a b n o r m a l i t i e s , b e c a u s e a r r h y t h m i a s a r eo f t e n r e f r a c t o r y t o a n y m e d i c a t i o n a n d b e c a u s e a t r i -o v e n t r i c u l a r b l o c k m a y r e q u i r e i m p l a n t a t i o n o f p e r -m a n e n t p a c e m a k e r . 3 ' 4 A l e s i o n o f c a r d i a c s a r c o i d o s i sm i g h t b e t o o s m a l l t o b e d e t e c t a b l e o n t h a l l i u m - 2 0 1s c i n t i g r a p h y i n o u r g r o u p B p a t i e n t s . A l t h o u g h c o r -t i c o s t e r o i d s w e r e n o t i n d i c a t e d i n s u c h p a t i e n t s w i t hi s o l a t e d , a s y m p t o m a t i c ECG a b n o r m a l i t i e s , t h e s ep a t i e n t s w h o h a d ECG a b n o r m a l i t i e s b u t n o m y o -c a r d i a l t h a l l i u m - 2 0 1 d e f e c t s m u s t b e o b s e r v e d c a r e -f u l l y .A m b u l a t o r y ECG i s u s e f u l t o d e t e c t p a r o x y s m a la r r h y t h m i a s a n d i n t e r m i t t e n t c o n d u c t i o n b l o c k . 3 I no u r s t u d y , we r e g a r d e d v e n t r i c u l a r a r r h y t h m i a s o fm o r e t h a n o r e q u a l t o t h i r d g r a d e o f L o w n ' s c l a s s i f i -c a t i o n a s " s e v e r e . " I n t h i s c a s e , t h e s e n s i t i v i t y a n ds p e c i f i c i t y w e r e 5 0 % a n d 8 9 % , r e s p e c t i v e l y . H a l f o fg r o u p A p a t i e n t s d i d n o t s h o w " s e v e r e " v e n t r i c u l a ra r r h y t h m i a s d e s p i t e o b v i o u s d e f e c t s o n m y o c a r d i a lt h a l l i u m - 2 0 1 s c i n t i g r a p h y . T h e s e f a l s e - n e g a t i v e c a s e sm a y g i v e a n e g a t i v e a s s e s s m e n t o f t h i s e x a m i n a t i o nb e c a u s e o f i t s l o w s e n s i t i v i t y .

M e a s u r e m e n t o f s e r u m ACE l e v e l s may b e u s e f u l

i n s u p p o r t i n g t h e d i a g n o s i s o f s a r c o i d o s i s a n d i n a s -s e s s i n g t h e r e s u l t s o f c o r t i c o s t e r o i d t h e r a p y . 1 2 I n o u rs t u d y , m e a n l e v e l s o f s e r u m ACE a n d l y s o z y m e w e r en o t d i f f e r e n t b e t w e e n t h e t w o g r o u p s . M e a s u r e m e n to f t h e s e e n z y m e s , t h e r e f o r e , may n o t b e u s e f u l t od e t e c t m y o c a r d i a l i n v o l v e m e n t s o f s a r c o i d o s i s .G a l l i u m - 6 7 s c i n t i g r a p h y i s a l s o u s e d t o d i a g n o s em y o c a r d i a l i n v o l v e m e n t s o f s a r c o i d o s i s . 1 5 I n o u rs t u d y , h a l f t h e p a t i e n t s w i t h c a r d i a c s a r c o i d o s i s h a dn o m y o c a r d i a l g a l l i u m - 6 7 u p t a k e s a n d t h e y w e r e n o tr e s p o n s i v e t o c o r t i c o s t e r o i d t h e r a p y . S u c h a l a c k o fg a l l i u m - 6 7 u p t a k e i n t h e r e g i o n w i t h t h a l l i u m - 2 0 1d e f e c t m a y i n d i c a t e t h e l e s i o n o f m y o c a r d i a l i n v o l v e -m e n t o f s a r c o i d o s i s w i t h o u t a c t i v e i n f l a m m a t i o n a n dm a y t h e r e f o r e s h o w a p o o r r e s p o n s e t o c o r t i c o s t e r -o i d s . A l b e r t s e t a l ' 0 d e m o n s t r a t e d t h a t a l a r g e d o s e o fc o r t i c o s t e r o i d s d e c r e a s e d t h e a c c u m u l a t i o n o f g a l l i -u m - 6 7 i n t h e p u l m o n a r y p a r e n c h y m a a n d h i l u m i np a t i e n t s w i t h p u l m o n a r y s a r c o i d o s i s . O ' C o n n e l l e ta l ' 6 s h o w e d t h a t g a l l i u m - 6 7 s c i n t i g r a p h y m a y b e a ni n d i c a t o r o f i n f l a m m a t o r y c h a n g e s t o g u i d e t h e u s e o fi m m u n o s u p p r e s s i v e a g e n t s s u c h a s p r e d n i s o l o n e a n da z a t h i o p r i n e i n p a t i e n t s w i t h c o n g e s t i v e c a r d i o m y -o p a t h y . When t h e s e r e s u l t s a p p l y t o c a r d i a c s a r c o i -d o s i s , t h e p a t i e n t s w i t h m y o c a r d i a l g a l l i u m - 6 7 u p -t a k e m a y b e r e s p o n s i v e t o c o r t i c o s t e r o i d t h e r a p y .T h e s e h y p o t h e s e s w e r e c o m p a t i b l e w i t h o u r r e s u l t s .C o n v e r s e l y , t h e p a t i e n t s w i t h o u t g a l l i u m - 6 7 u p t a k em a y h a v e n o a c t i v e i n f l a m m a t i o n a n d m a y n o t b er e s p o n s i v e t o c o r t i c o s t e r o i d t h e r a p y . M y o c a r d i a l g a l -l i u m - 6 7 s c i n t i g r a p h y may t h e r e f o r e b e u s e f u l t op r e d i c t t h e e f f e c t o f c o r t i c o s t e r o i d t h e r a p y .

I n c o n c l u s i o n , t h e d i a g n o s i s o f c a r d i a c s a r c o i d o s i sw i t h e n l a r g e d C T R , v e n t r i c u l a r a r r h y t h m i a s , o rh e a r t b l o c k may b e t o o l a t e t o p r e v e n t c a r d i a c a c c i -d e n t s , b e c a u s e t h e s e c a r d i a c s i g n s a r e b a s e d o n t h ep e r m a n e n t m y o c a r d i a l d e r a n g e m e n t s t h a t o f t e n d on o t i m p r o v e w i t h c o r t i c o s t e r o i d t h e r a p y . M y o c a r d i a lt h a l l i u m - 2 0 1 s c i n t i g r a p h y m u s t t h e r e f o r e b e p e r -f o r m e d w h e n e v e r t h e d i a g n o s i s o f c a r d i a c s a r c o i d o -s i s i s s u s p e c t e d . P a t i e n t s w i t h m y o c a r d i a l g a l l i u m - 6 7u p t a k e may b e r e s p o n s i v e t o c o r t i c o s t e r o i d t h e r a p y .T h u s , t h e c o m b i n a t i o n o f t h a l l i u m - 2 0 1 a n d g a l l i -u m - 6 7 m y o c a r d i a l s c i n t i g r a p h y i s u s e f u l i n t h e d i a g -n o s i s o f c a r d i a c s a r c o i d o s i s a n d t h e p r e d i c t i o n o f r e -

CHEST / 1 0 7 / 2 / F E B R U A R Y , 1 9 9 5 3331995, by the American College of Chest Physicians

at Ohio State University on March 4, 2011chestjournal.chestpubs.orgDownloaded from

http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/

8/4/2019 Cardiac Sarcoid

6/7

sp o n s e t o c o r t i c o s t e r o i d t h e r a p y .R E F E R E N C E S

1 F a n b u r g B L . S a r c o i d o s i s . I n : W y n g a a r d e n J B , S m i t h L H , B e n -n e t t J C , e d s . C e c i l t e x t b o o k o f m e d i c i n e . P h i l a d e l p h i a : WBS a u n d e r s , 1 9 9 2 ; 4 3 0 - 3 5

2 C r y s t a l R G . S a r c o i d o s i s . I n : W i l s o n J D , B r a u n w a l d E , I s s e l -b a c h e r K J , P e t e r s d o r f R G , M a r t i n J B , F a u c i A S , e t a l , e d s .H a r r i s o n ' s p r i n c i p l e s o f i n t e r n a l m e d i c i n e . N e w Y o r k : M c -G r a w - H i l l , 1 9 9 1 ; 1 4 6 3 - 6 9

3 Wenger N K , A b e l m a n n W H , R o b e r t s WC. C a r d i o m y o p a t h ya n d s p e c i f i c h e a r t m u s c l e d i s e a s e . I n : H u r s t J W , e d . T h e h e a r t .N e w Y o r k : M c G r a w - H i l l , 1 9 9 0 ; 1 2 7 8 - 1 3 4 74 W y n n e J , B r a u n w a l d E . T h e c a r d i o m y o p a t h y a n d m y o c a r d i t i s .I n : B r a u n w a l d E , e d . H e a r t d i s e a s e . P h i l a d e l p h i a : WB S a u n -d e r s , 1 9 8 0 ; 1 4 3 7 - 9 85 S i l v e r m a n K J , H u t c h i n s GM, B u l k l e y B H . C a r d i a c s a r c o i d : ac l i n i c o p a t h o l o g i c a l s t u d y o f 8 4 u n s e l e c t e d p a t i e n t s w i t h s y s -

t e m i c s a r c o i d o s i s . C i r c u l a t i o n 1 9 7 8 ; 5 8 : 1 2 0 4 - 1 16 S h a r m a O P , M a h e s h w a r i A , T h a k e r K . M y o c a r d i a l s a r c o i d o s i s .

C h e s t 1 9 9 3 ; 1 0 3 : 2 5 3 - 5 87 R a t n e r S J , F e n o g l i o J J , U r s e l l P C . U t i l i t y o f e n d o m y o c a r d i a lb i o p s y i n t h e d i a g n o s i s o f c a r d i a c s a r c o i d o s i s . C h e s t 1 9 8 6 ;

9 0 : 5 2 8 - 3 38 B u l k l e y B H , R o u l e a u J B , W h i t a k e r J Q , S t r a u s s H W, P i t t B . T h e

u s e o f 2 0 1 t h a l l i u m f o r m y o c a r d i a l p e r f u s i o n i m a g i n g i n s a r c o i dh e a r t d i s e a s e . C h e s t 1 9 7 7 ; 7 2 : 2 7 - 3 2

9 K i n n e y E L , J a c k s o n G L , R e e v e s WC, Z e l i s R , B e e r s E . T h a l l i u ms c a n m y o c a r d i a l d e f e c t s a n d e c h o c a r d i o g r a p h i c a b n o r m a l i t i e si n p a t i e n t s w i t h s a r c o i d o s i s w i t h o u t c l i n i c a l c a r d i a c d y s f u n c t i o n .Am J Me d 1 9 8 0 ; 6 8 : 4 9 7 - 5 0 3

1 0 A l b e r t s C , Va n d e r S c h o o t J B , G r o e n A S . G a - 6 7 s c i n t i g r a p h y asan i n d e x o f d i s e a s e a c t i v i t y i n p u l m o n a r y s a r c o i d o s i s . E u r J N u c lMe d 1 9 8 0 ; 6 : 2 0 5 - 1 2

1 1 K u r a t a C , S a k a t a K , T a g u c h i T , F u k u m o t o Y , M i y a t a H ,A o s h i m a S , e t a l . SPECT i m a g i n g w i t h T 1 - 2 0 1 a n d G a - 6 7 i nm y o c a r d i a l s a r c o i d o s i s . C l i n N u c l Me d 1 9 9 0 ; 1 5 : 4 0 8 - 1 1

1 2 T a w a r a h a r a K , K u r a t a C , O k a y a m a K , K o b a y a s h i A , Y a m a z a k iN . T h a l l i u m - 2 0 1 a n d g a l l i u m - 6 7 s i n g l e p h o t o n e m i s s i o n com-p u t ed t o m o g r a p h i c i m a g i n g i n c a r d i a c s a r c o i d o s i s . Am H e a r t J1 9 9 2 ; 1 2 4 : 1 3 8 3 - 8 4

1 3 T e l l i e r P , V a l e y r e A , N i t e n b e r g A , F o u l t J M , B e d i g G , B a t t e s t iJ P . C a r d i a c s a r c o i d o s i s : r e v e r s i o n o f m y o c a r d i a l p e r f u s i o n a b -n o r m a l i t i e s b y d i p y r i d a m o l e . E u r J N u c l Me d 1 9 8 5 ; 1 1 : 2 0 1 - 0 41 4 C h i l e s C , A d a m s GW , R a v i n C E. R a d i o g r a p h i c m a n i f e s t a t i o no f c a r d i a c s a r c o i d o s i s . A J R 1 9 8 5 ; 1 4 5 : 7 1 1 - 1 41 5 F o r m e n M B , S a n d l e r M P , S a c k s G A , K r o n e n b e r g MW , P o w e r s

T A . R a d i o n u c l i d e i m a g i n g i n m y o c a r d i a l s a r c o i d o s i s : d e m o n -s t r a t i o n o f m y o c a r d i a l u p t a k e o f t e c h n e t i u m p y r o p h o s p h a t e99m a n d g a l l i u m . C h e s t 1 9 8 3 ; 8 3 : 5 7 8 - 8 01 6 O ' C o n n e l l J B , H e n k i n R E , R o b i n s o n J A , S u b r a m a n i a n R , P a t hMRC, S c a n l o n P J , e t a l . G a l l i u m - 6 7 i m a g i n g i n p a t i e n t s w i t hd i l a t e d c a r d i o m y o p a t h y a n d b i o p s y - p r o v e n m y o c a r d i t i s . C i r -c u l a t i o n 1 9 8 4 ; 7 0 : 5 8 - 6 2

M y o c a r d i a l S c i n t i g r a p h y W i t h T I - 2 0 1 a n d G a - 6 7 i n S a r c o i d o s i s ( O k a y a m a e t a l )

34TH A n n u a l D u r r a n c e - W a r i n g M i d - W i n t e r C h e s t C o n f e r e n c eF e b r u a r y 2 1 - 2 5 , 1 9 9 5 ; A s p e n , C o l o r a d o

S p o n s o r e d b y t h e C o l o r a d o T r u d e a u S o c i e t y a n d t h e A m e r i c a n L u n g A s s o c i a t i o n o f C o l o r a d o .F o r i n f o r m a t i o n , c o n t a c t : t h e A m e r i c a n L u n g A s s o c i a t i o n o f C o l o r a d o , 1 6 0 0 R a c e S t r e e t , D e n v e r CO8 0 2 0 6 . T e l : 3 0 3 3 8 8 - 4 3 2 7 o r F a x : 3 0 3 3 7 7 - 1 1 0 2 . l

3 3 41995, by the American College of Chest Physicians

at Ohio State University on March 4, 2011chestjournal.chestpubs.orgDownloaded from

http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/

8/4/2019 Cardiac Sarcoid

7/7

DOI 10.1378/chest.107.2.330

1995;107; 330-334ChestWakabayashi, Kingo Chida and Atsuhiko Sato

Kenichi Okayama, Chinori Kurata, Kei Tawarahara, YasushiThallium-201 and Gallium-67 in Cardiac Sarcoidosis

Diagnostic and Prognostic Value of Myocardial Scintigraphy With

March 4, 2011This information is current as of

http://chestjournal.chestpubs.org/content/107/2/330Updated Information and services can be found at:

Updated Information & Services

http://chestjournal.chestpubs.org/content/107/2/330#related-urlsThis article has been cited by 12 HighWire-hosted articles:

Cited Bys

http://www.chestpubs.org/site/misc/reprints.xhtmlbe found online at:Information about reproducing this article in parts (figures, tables) or in its entirety canPermissions & Licensing

http://www.chestpubs.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

Reprints

"Services" link to the right of the online article.Receive free e-mail alerts when new articles cite this article. To sign up, select the

Citation Alerts

PowerPoint slide format. See any online figure for directions.articles can be downloaded for teaching purposes inCHESTFigures that appear in

Images in PowerPoint format

1995 by the American College of Chest Physiciansat Ohio State University on March 4, 2011chestjournal.chestpubs.orgDownloaded from

http://chestjournal.chestpubs.org/content/107/2/330http://chestjournal.chestpubs.org/content/107/2/330http://chestjournal.chestpubs.org/content/107/2/330http://chestjournal.chestpubs.org/content/107/2/330#related-urlshttp://chestjournal.chestpubs.org/content/107/2/330#related-urlshttp://www.chestpubs.org/site/misc/reprints.xhtmlhttp://www.chestpubs.org/site/misc/reprints.xhtmlhttp://www.chestpubs.org/site/misc/reprints.xhtmlhttp://www.chestpubs.org/site/misc/reprints.xhtmlhttp://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://chestjournal.chestpubs.org/http://www.chestpubs.org/site/misc/reprints.xhtmlhttp://www.chestpubs.org/site/misc/reprints.xhtmlhttp://chestjournal.chestpubs.org/content/107/2/330#related-urlshttp://chestjournal.chestpubs.org/content/107/2/330