Patients with cardiac sarcoidosis may experience palpitations and symptoms of heart failure that can be misdiagnosed as the psychiatric symptoms of panic disorder, according to a new case report.
“Cardiac Sarcoidosis Resembling Panic Disorder: A Case Report” was published in the journal BMC Psychiatry.
Panic disorder refers to repeated panic attacks and the anxiety caused by anticipation of these attacks. The condition may be caused by physical diseases such as brain cancer or arrhythmias.
Cardiac lesions due to sarcoidosis may lead to fatal arrhythmias or heart failure. In fact, previous studies have suggested that patients with sarcoidosis have a higher risk of developing panic disorder compared to the general population, but it was still not clear whether this association really exists.
Researchers have now reported the case of a 57-year-old woman who went to the hospital complaining of sudden palpitations and dyspnea (shortness of breath). A medical exam showed that the patient had ventricular tachycardia (fast heartbeat), which disappeared spontaneously after awhile. Although doctors tried to discover the cause for the condition, they were unsuccessful and the patient was dismissed.
However, the patient reported palpitations and dyspnea episodes almost once a month, so doctors performed several exams, including electrocardiograms, chest radiographies and blood analyses. Still, nothing was found that could explain the symptoms.
Doctors began to suspect that the symptoms could be due to a psychological condition, so they referred the patient to a neuropsychiatrist.
“The patient experienced palpitations and dyspnea at rest without any apparent cause,” the researchers wrote. “These symptoms sometimes continued for two to three hours. During each incident, the patient experienced a strong fear of dying. She also experienced strong anticipatory anxiety and left her house less frequently than she used to because of the fear that palpitations would occur.”
As further physical examinations failed to reveal a cause for her condition, doctors diagnosed her as having panic disorder. The patient received cognitive behavioral therapy and drug treatment (alprazolam 1.2 mg daily and mirtazapine 15 mg a day).
However, the panic attacks remained and their frequency worsened until the patient began experiencing the attacks every day.
A new electrocardiogram then showed a cardiac pause (maximal 32 seconds) due to a transient complete atrioventricular block. Her doctors then implanted a permanent pacemaker, which improved the patient’s panic attacks, anxiety, and fear of death.
But one month after the intervention, the patient was re-admitted to the hospital with symptoms of heart failure. More exams led the doctors to diagnose her with cardiac sarcoidosis. The patient began steroid treatment (prednisolone 30 mg a day) for this condition, which improved her heart function and symptoms.
“This improvement indicated that the cause of complete atrioventricular block was associated with cardiac sarcoidosis,” the researchers concluded. “Therefore, the set of symptoms that were initially attributed to panic disorder were actually caused by a complete atrioventricular block associated with cardiac sarcoidosis, which secondarily caused panic attacks.”
“The current case report highlights the importance of considering cardiac sarcoidosis in the differential diagnosis of panic disorder,” the team added. “The condition described [here] appears to constitute a physical disease for which caution is required in psychiatric diagnosis.”