Medical Mystery: Coughing and nausea for several months

A woman in her 50s went to her family doctor with a variety of symptoms that could have indicated any number of conditions. She had shortness of breath, coughing, wheezing, nausea, stomach pains, dizziness, and fatigue. Her doctor, noting that she also was significantly overweight and out of shape, believed she was suffering from asthma, and prescribed asthma and antinausea medications.

Still, the symptoms persisted for several months. Looking for an answer, the woman went to both a respiratory specialist and digestive specialist, but neither offered treatments that helped her.

Finally, one of her doctors, on the theory that she might have a heart problem, sent her to my office.

After her workup, I suspected that she suffered from cardiomyopathy, a chronic disease in which the heart muscle becomes enlarged, weakened and has a harder time pumping blood. It can lead to heart failure, causing fluid to build up in various parts of the body.

We put her on medication and ran some tests, including an echocardiogram, a cardiac catheterization to look at her arteries, and a magnetic resonance imaging scan or MRI.

Her symptoms, especially the breathing problems and fatigue, were consistent with cardiomyopathy. However, after examining the patient's MRI results, something was not adding up.

The MRI revealed evidence that her heart either had been injured in the past or was still being harmed by some kind of inflamation. The next step was to order a positron emission tomography or PET scan of the heart. This is a noninvasive test that uses radioactive tracers to show your heart's metabolic activity. Computer graphics can produce 3-D images that show how well the heart muscle is working, according to how much of the tracer the heart tissue takes up.

The test showed increased metabolic activity in her lymph nodes and heart. That told us we needed to get a sample of her lymph nodes to examine in the lab.

Finally, we got our answer: My patient's heart was weakened by an inflammatory condition called cardiac sarcoidosis.

In sarcoidosis, clusters of white blood cells called granulomas form in the tissue. It can appear in any organ, but most commonly affects the lungs. When it strikes the heart, it can affect every part of the organ including the arteries, valves, and the electrical system.

My patient is taking steroids as well as cardiac medications including beta blockers, ACE inhibitors and diuretics as necessary to control her symptoms and limit further damage.

The cause of cardiac sarcoidosis is unknown. Because its symptoms can suggest many more common conditions such as asthma, an upper respiratory infection or even the flu, it's difficult to diagnose.

Fortunately, my patient was persistent in seeking answers. It is important for doctors to take continued symptoms very seriously. Cardiac sarcoid is uncommon, but I suspect many cases are not detected, which is a shame as it is potentially a treatable and even reversible disease.

Rene Alvarez, M.D., is vice chief of cardiology and director of the Heart Failure/Cardiac Transplantation Program at the Temple Heart and Vascular Institute, and professor of medicine at the Lewis Katz School of Medicine at Temple University.