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Cardiac sarcoidosis resembling panic disorder: a case report
© The Author(s). 2017
Received: 3 August 2016
Accepted: 30 December 2016
Published: 13 January 2017
Sarcoidosis is a systemic disease of unknown etiology, in which granulomas develop in various organs, including the skin, lungs, eyes, or heart. It has been reported that patients with sarcoidosis are more likely to develop panic disorder than members of the general population. However, there are many unknown factors concerning the causal relationship between these conditions.
We present the case of a 57-year-old woman who appeared to have panic disorder, as she experienced repeated panic attacks induced by transient complete atrioventricular block, associated with cardiac sarcoidosis. Psychotherapy and pharmacotherapy were not effective in the treatment of her panic attacks. However, when we implanted a permanent pacemaker and initiated steroid treatment for cardiac sarcoidosis, panic attacks were ameliorated. Based on these findings, we diagnosed the patient’s symptoms as an anxiety disorder associated with cardiac sarcoidosis, rather than panic disorder.
This report highlights the importance of considering cardiac sarcoidosis in the differential diagnosis of panic disorder. This cardiac disease should be considered especially in patients have a history of cardiac disease (e.g., arrhythmia) and atypical presentations of panic symptoms. Panic disorder is a psychiatric condition that is typically diagnosed after other medical conditions have been excluded. Because the diagnosis of sarcoidosis is difficult in some patients, caution is required. The palpitations and symptoms of heart failure associated with cardiac sarcoidosis can be misdiagnosed as psychiatric symptoms of panic disorder. The condition described in the current case study appears to constitute a physical disease, the diagnosis of which requires significant consideration and caution.
Panic disorder is characterized by repeated panic attacks and anticipatory anxiety concerning these attacks . Importantly, exclusion of other physical diseases is required for a diagnosis of panic disorder . Because panic attacks may be caused by physical diseases, such as hyperthyroidism, brain tumors, or arrhythmias, panic disorder should be diagnosed with caution .
Sarcoidosis is a systemic disease of unknown etiology in which granulomas develop in various organs (e.g., the skin, lungs, eyes, or heart) . Cardiac lesions are specifically referred to as cardiac sarcoidosis, a condition that can lead to fatal arrhythmias or heart failure . It has been reported that 44% of patients with sarcoidosis experience comorbid psychiatric disorders, with panic disorder observed in 6.3% of cases . The prevalence of panic disorder among patients with sarcoidosis is higher than that of the 2.7% reported in the general population . However, many aspects of the causal relationship between these conditions are currently unknown.
In the case described in this report, differentiating cardiac sarcoidosis from panic disorder was difficult. According to the DSM-5, the diagnosis of panic disorder is applied in cases of repeated and unexpected panic attacks, where the condition is defined as not being caused by the physiological effect of a substance or other medical condition (e.g., hyperthyroidism or a cardiopulmonary disorder) . Panic attacks are psychiatric symptoms in which sudden severe fear or discomfort increases and peaks within a few minutes, and four of 13 symptoms (palpitations, sweating, trembling, sensations of shortness of breath, feelings of choking, chest pain, nausea, dizziness, chills, paresthesia, derealization, fear of losing control, or fear of dying) occur during that time . In the case described in the current report, the patient exhibited palpitations, dyspnea, chest pain, and fear of death. Furthermore, the patient experienced anticipatory anxiety of panic attacks, and because of the fear of future attacks, the frequency with which she was able to leave her house decreased. Although the patient had a history of one episode of ventricular tachycardia, an outpatient cardiovascular examination revealed no structural abnormalities to explain the repeated palpitations, and the patient was referred to the department of psychiatry. The examination indicated that the patient’s thyroid function was normal, and no other structural abnormalities were noted at the initial visit. Therefore, we assumed that the palpitations were due to panic disorder. Thus, we initiated psychotherapy and the administration of psychotropic medication, but observed no therapeutic effects. During the clinical course, it became clear that the cause of panic attacks was complete atrioventricular block associated with cardiac sarcoidosis and transient sinus tachycardia following recovery from the cardiac pause. Because the attacks were not frequent and occurred approximately once a month, it was difficult to detect the electrocardiographic abnormalities using a 24-h ambulatory electrocardiogram, which may have contributed to the delay in the diagnosis. To perform an accurate diagnosis earlier, it may have been useful to use an implantable loop recorder to analyze electrocardiographic findings during attacks . Although our patient was inserted a permanent pacemaker to treat complete atrioventricular block, it was initially not possible to diagnose her with cardiac sarcoidosis. Furthermore, ventricular tachycardia was only noted once during the initial presentation, and its relationship with the subsequent cardiac sarcoidosis was unclear. However, considered retrospectively, the ventricular tachycardia and complete atrioventricular block might have appeared as a series of symptoms caused by cardiac sarcoidosis. When a treatment plan is determined, implantation of a dual chamber pacemaker/defibrillator should be considered to treat recurrence of ventricular tachycardia [7, 8]. However, the possibility of depression, anxiety, or other emotional impact that could result from ICD implantation should also be considered , especially because our patient had a history of panic attacks and anxiety disorder. We suggest that sufficient patient-physician communication is important before ICD implantation .
An increasing number of recent studies have reported a relationship between sarcoidosis and psychiatric disorders. In the general population, the prevalence rate of panic disorder is reportedly 2.7% . By contrast, Goracci et al. reported that 6.3% of patients with sarcoidosis also exhibit panic disorder, and 25% of patients with cardiac sarcoidosis also have depression, while 5% also have an anxiety disorder . A possible relationship between the decrease in respiratory function and psychiatric symptoms (e.g., anxiety disorder and depressive disorders) has been suggested . But there are many unknown factors concerning the causal relationship between the conditions. Psychiatric manifestations, including apathy, delirium and depression, occur in about 20% of patients with neurosarcoidosis, reflecting the potential for granulomatous infiltration of any part of the central nervous system . In a study examining paroxysmal supraventricular tachycardia, Colucci et al. noted that some patients receiving a delayed diagnosis of arrhythmia are initially misdiagnosed as having panic disorder . As observed in the present case, it is possible for patients with arrhythmia associated with cardiac sarcoidosis causing panic attacks in whom physical diseases have been overlooked to be misdiagnosed with panic disorder. However, no previous reports have highlighted the importance of differentiating cardiac sarcoidosis from panic disorder.
In cases of cardiac sarcoidosis, in conjunction with the progression of the disease, clinical symptoms, such as dizziness, syncope, palpitations, and dyspnea, are typically observed due to cardiac dysfunction. However, because these symptoms are nonspecific and the progression of the disease is slow, diagnosis is often delayed. According to autopsy reports of patients with sarcoidosis, cardiac involvement is present in at least 27% of cases , but cardiac sarcoidosis is clinically observed in only 5% of patients . This finding indicates that many cardiac lesions are overlooked ante mortem [2, 14]. In our case, echocardiography revealed basal thinning of the interventricular septum, a characteristic feature of cardiac sarcoidosis, which served as the steppingstone that led to the accurate diagnosis of this condition [15, 16]. Thus, echocardiography should be considered in patients who develop new-onset panic attacks at an older age as panic disorder or in individuals with a history of arrhythmias or other cardiac problems that could lead to panic-like symptoms.
Although sarcoidosis spontaneously subsides over time in some patients, caution is required, as fatal cases of arrhythmia and severe heart failure may develop in patients with cardiac involvement. Histological diagnosis of cardiac sarcoidosis requires myocardial biopsy, but diagnostic sensitivity is low (19.2%) . Thus, it is necessary to consider early steroid treatment based on the clinical diagnosis when cardiac sarcoidosis is clinically suspected [18, 19].
Because panic disorder is a psychiatric disorder in which diagnosis is contingent on excluding other physical symptoms, in the case of indolent diseases, accurate differentiation during the initial stages of the disorder is difficult. Therefore, it is important to differentiate physical diseases when psychiatric treatment initiated under the diagnosis of panic disorder is ineffective.
The current case report highlights the importance of considering cardiac sarcoidosis in the differential diagnosis of panic disorder. This cardiac disease should be considered especially the patients have a history of cardiac disease (e.g., arrhythmia) and atypical presentations of panic symptoms.
Panic disorder is a psychiatric disorder that is diagnosed after other medical conditions have been excluded. Because differentiation is difficult in some patients, caution is required. Moreover, it is possible for palpitations and heart failure symptoms associated with cardiac sarcoidosis to be misdiagnosed as psychiatric symptoms of panic disorder. Therefore, the condition described in the present report appears to constitute a physical disease for which caution is required in psychiatric diagnosis.
The authors would like to thank all of their coworkers of Towada City Hospital on this case for their skillful contributions.
There was no funding source.
Availability of data and materials
The diagnostic findings are mentioned in the paper.
KT and JD treated the patient and wrote the paper. YY, SO, JT, KY, and NYF critically reviewed the diagnostic results and contributed to the manuscript preparation. All authors read and approved the final version of the manuscript.
KT, JD, YY, SO, JT and KY have no competing interests. NYF has received grant/research support or honoraria from and been on the speakers’ bureaus of Astellas Pharma, Dainippon Sumitomo Pharma, Eli Lilly and Company, GlaxoSmithKline, Janssen Pharmaceutical, Meiji Seika Pharma, Mochida Pharmaceutical Company, MSD K.K., Otsuka Pharmaceutical, Pfizer, TAKEDA Pharmaceutical and Yoshitomiyakuhin Corporation. These funders do not specifically relate to this study in design, data collection and analysis, decision to publish, or preparation of the manuscript.
Consent for publication
The patient has given her consent for the details of the case report and for the figure to be published. A copy of the signed written informed consent to publish has been made available to the editor of the journal.
Ethics approval and consent to participate
We adhered to CARE guidelines/methodology.
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