Bi-fascicular block on EKG as the initial presenting sign of cardiac sarcoidosis.

A 41-year-old commercial painter with a history of tobacco use presented to the emergency department with complaints of cough, pleuritic chest pain and worsening dyspnea with exertion beginning 3 days prior to arrival. He had not responded to an outpatient regimen of bronchodilators and antibiotics. The patient denied any constitutional symptoms. On initial examination, the patient was afebrile with a room air oxygen saturation of 82%. Pulmonary examination revealed tachypnea with accessory muscle use and the presence of dry crackles in the posterior lung bases bilaterally and diffuse expiratory wheezing. Cardiovascular examination revealed mild jugular venous distention suggestive of right-sided heart failure. The rest of the patient’s physical exam was normal. A chest X-ray done did not show any evidence of air-space disease. Electrocardiogram (EKG) revealed sinus tachycardia with a rate of 110 and evidence of right bundle branch block and left anterior fascicular block (Fig. 1a). Thiswas not seen on a prior EKG from 1 year ago. Initial laboratory studies were unrevealing and serial sets of troponin I and CKMB showed no evidence of myocardial necrosis. The presence of bi-fascicular block on ECG in absence of any signs of myocardial ischemia prompted to consider the diagnosis of infiltrative myocardial disease. A cardiac MRI was obtained. Gadolinium-enhanced cardiac MRI (Fig. 1b) revealed abnormal signals seen in the right ventricular