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doi: https://doi.org/10.4132/jptm.2020.06.10    [Epub ahead of print]
Indirect pathological indicators for cardiac sarcoidosis on endomyocardial biopsy
Myung-Jin Cha1 , Jeong-Wook Seo2 , Seil Oh3,4 , Eun-Ah Park5 , Sang-Han Lee6,7 , Moon Young Kim8 , Jae-Young Park9
1Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
2Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
3Department of Internal Medicine and Interdisciplinary Program for Bioengineering, Seoul National University College of Medicine, Seoul, Korea
4Cardiology Division, Cardiovascular Center, and Cardiac Electrophysiology Lab, Seoul National University Hospital, Seoul, Korea
5Division of Cardiovascular Imaging, Department of Radiology, Seoul National University Hospital, Seoul, Korea
6Department of Forensic Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
7Department of Pathology, Kyungpook National University Hospital, Daegu, Korea
8Department of Radiology, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
9Department of Pathology, Sejong Hospital, Bucheon, Korea
Corresponding Author: Jeong-Wook Seo ,Tel: +82-2-740-8268, Fax: +82-2-765-5600, Email: jwseo@snu.ac.kr
Received: December 17, 2019;  Revised: June 2, 2020  Accepted: June 10, 2020.  Published online: July 29, 2020.

The definitive pathologic diagnosis of cardiac sarcoidosis requires observation of a granuloma in the myocardial tissue. It is common, however, to receive a “negative” report for a clinically probable case. We would like to advise pathologists and clinicians on how to interpret “negative” biopsies.
Our study samples were 27 endomyocardial biopsies from 25 patients, three cardiac transplantation and an autopsied heart with suspected cardiac sarcoidosis. Pathologic, radiologic, and clinical features were compared.
The presence of micro-granulomas or increased histiocytic infiltration was always (6/6 or 100%) associated with fatty infiltration and confluent fibrosis, and they showed radiological features of sarcoidosis. Three of five cases (60%) with fatty change and confluent fibrosis were probable for cardiac sarcoidosis on radiology. When either confluent fibrosis or fatty change was present, one-third (3/9) were radiologically probable for cardiac sarcoidosis. We interpreted cases with micro-granuloma as positive for cardiac sarcoidosis (five of 25, 20%). Cases with both confluent fibrosis and fatty change were interpreted as probable for cardiac sarcoidosis (seven of 25, 28%). Another 13 cases, including eight cases with either confluent fibrosis or fatty change, were interpreted as low probability based on endomyocardial biopsy.
The presence of micro-granuloma could be an evidence for positive diagnosis of cardiac sarcoidosis. Presence of both confluent fibrosis and fatty change is necessary for probable cardiac sarcoidosis in the absence of granuloma. Either of confluent fibrosis or fatty change may be an indirect pathological evidence but they are interpreted as nonspecific findings.
Key Words: Myocarditis; Arrhythmogenic right ventricular dysplasia; Tachycardia, ventricular; Sarcoidosis; Cardiac muscle
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