Faculty Bibliography

[This corrects the article DOI: 10.1371/journal.pone.0194541.].

Learning Objective #1: Diagnose cardiac sarcoidosis with cardiac MRI instead of lower yield endomyocardial biopsy. Learning Objective #2: Recognize role of steroids and ICD in treating cardiac sarcoidosis with heart block or heart failure. CASE: A 59-year-old man with a history of type II diabetes, hypertension, and hyperlipidemia presented with progressive dyspnea on exertion for four weeks. On exam, the patient was tachycardic with an elevated jugular venous pressure of ~16 cmH2O, bibasilar rales, and bilateral lower extremity 2+ pitting edema. Labs were notable for an elevated BNP and pancytopenia. EKG revealed new bifascicular block. Echocardiogram demonstrated diffuse hypokinesis and severely reduced right and left ejection fractions (EF). Coronary catheterization showed no ischemia. Cardiac MRI showed late patchy gadolinium enhancement suggestive of cardiac sarcoid. Chest CT was consistent with pulmonary sarcoid, and showed a right pleural effusion found to be exudative. Video-assisted thoroscopic biopsy with evidence of non-necrotizing granulomas with no evidence of infection confirmed the diagnosis. Glucocorticoids and neuro-hormonal blockade were initiated and an automatic implantable cardioverter-defibrillator (ICD) was placed. By three months, his dyspnea had improved and his EF had recovered to 50%. IMPACT: Cardiac involvement is present in up to 25% of sarcoid patients, although it manifests clinically in only 5%¹ Therefore, hospitalists must maintain a high index of suspicion for cardiac sarcoidosis in patients with new onset non-ischemic cardiomyopathy or conduction disease. With few exceptions, tissue diagnosis is required. This is a challenge in patients with isolated cardiac sarcoidosis since endomyocardial biopsy has adiagnostic yield below 20% ¹ As such, cardiac MRI is an invaluable tool in the work up of non-ischemic cardiomyopathy. It is the diagnostic test of choice for cardiac sar-coidosis with a sensitivity of 100% and specificity of 80%.² Suspected non-cardiac sites should be biopsied when available. Prompt initiation of steroid therapy is indicated based upon available observational data, and placement of an ICD is recommended in those with new heart block or severely reduced ejection fraction ^1,3 DISCUSSION: Sarcoidosis should be considered in young patients presenting with new heart block as well as patients with non-ischemic cardiomyopathy. Hospitalists must be aware of the diagnostic value of cardiac MRI in evaluating non-ischemic cardiomyopathy and the prevalence of cardiac involvement in sarcoidosis as prompt treatment is critical to prevent further morbidity and mortality

BACKGROUND:Mechanisms underlying the heightened myocardial infarction risk among HIV-infected women (versus non-HIV-infected women) remain unclear. Our objectives were to assess epicardial adipose tissue (EAT) volume and its associations among asymptomatic women with and without HIV. METHODS:A total of 55 HIV-infected and 27 non-HIV-infected women without known cardiovascular disease who underwent cardiac CT and metabolic/immune phenotyping were included. EAT volume derived from CT was compared among women with and without HIV, and within-group EAT associations were assessed. Next, immune and atherosclerotic plaque parameters were compared among groups stratified by HIV serostatus and high/low EAT (defined in reference to median EAT for each serostatus group). RESULTS:[P=0.04]; P for overall ANOVA) and were highest among HIV-infected women with excess EAT (versus HIV-infected women without excess EAT, non-HIV-infected women with excess EAT and non-HIV-infected women without excess EAT). The percentage of segments with non-calcified coronary plaque also differed by HIV serostatus/EAT volume subgroup and was highest among HIV-infected women with excess EAT. CONCLUSIONS:Asymptomatic women with and without HIV have similar volumes of EAT, but drivers of EAT may differ between groups. HIV-infected women with excess EAT have highest-level immune activation and the highest percentage of non-calcified plaque. Future studies are needed to determine whether EAT contributes pathogenetically to HIV-associated cardiovascular disease in women.

The etiology of monoclonal gammopathy of undetermined significance (MGUS), the precursor state of multiple myeloma (MM), is mostly unknown and no studies have been conducted on the effect of diet on MGUS or progression from MGUS to MM. We aimed to explore the association between common foods and MGUS and progression to MM. Data from the population-based AGES Study (N = 5,764) were utilized. Food frequency questionnaire was used to assess dietary intake during adolescence, midlife, and late life. Serum protein electrophoresis and serum free light-chain assay was performed to identify MGUS (n = 300) and LC-MGUS cases (n = 275). We cross linked our data with the Icelandic Cancer Registry to find cases of MM in the study group. We found that intake of fruit at least three times per week during adolescence was associated with lower risk of MGUS when compared to lower fruit consumption (OR = 0.62, 95% CI 0.41-0.95). We additionally found that intake of fruit at least three times per week during the late life period was associated with decreased risk of progressing from MGUS to MM (HR = 0.34, 95% CI 0.13-0.89) when compared to lower intake. Adolescent intake of fruit may reduce risk of MGUS, whereas fruit intake after MGUS onset may reduce risk of progressing to MM. Our findings suggest that diet might alter the risk of developing MGUS and progression to MM.