ABC | Volume 110, Nº6, June 2018

Anatomopathological Correlation Arduine & Aiello Female patient with chagas disease, heart failure and cachexia Arq Bras Cardiol. 2018; 110(6):588-596 the cases, on postmortem examination, it can range from 10% to 76%, causing bundle-branch block, repolarization disorders, arrhythmias and cardiomyopathy. 2,3 Isolated cardiac sarcoidosis can occur in up to 25% of the cases; thus, absence of extracardiac sarcoidosis does not exclude heart involvement. 4,5 The most common clinical characteristic of cardiac sarcoidosis is biventricular heart failure, with or without evidence of noncardiac involvement. In addition, mitral regurgitation can be severe and caused by the involvement of the papillary muscle, which could explain this patient’s mitral regurgitation. 6 Ventricular arrhythmias (sustained or non-sustained ventricular tachycardia and premature ventricular beats) are the second most common clinical presentation of cardiac sarcoidosis, occurring in approximately 30% of the cases. 7 The echocardiographic findings in patients with cardiac sarcoidosis vary and can include focal areas of edema, resulting in wall thickening and hypertrophic cardiomyopathy mimicking (for example, asymmetric septal hypertrophy), or, in more advanced patterns of involvement, focal areas of akinesia, dyskinesia or aneurysm. 8 Although cardiac sarcoidosis has been described as a restrictive cardiomyopathy, its most common phenotype is dilated cardiomyopathy, with occasional aneurysm formation. 6 Because the above described disease has many findings in common with those of our patient, our clinical hypothesis is systemic sarcoidosis with cardiac and pulmonary involvement. Figure 8 – Gross examination: aneurysmal thinning of the left ventricular lateral wall, with fibrous replacement of the myocardium (arrows). The left atrium (asterisk) is extremely dilated. However, infectious causes for the respiratory impairment cannot be ruled out, the most common and prevalent in Brazil being tuberculosis, which also forms granulomas. It is worth noting, however, that sarcoid granulomas are usually “non-caseating”, that is, have no necrosis. Thus, the lymph node biopsy of our patient does not support that diagnosis. (Gustavo Alonso Arduine, MD) Diagnostic hypothesis: syndromic: heart failure with reduced ejection fraction; etiological: systemic sarcoidosis (cardiac and pulmonary). (Gustavo Alonso Arduine, MD) Final finding: Mixed septic and cardiogenic shock (Gustavo Alonso Arduine, MD) Postmortem examination The postmortem examination revealed an emaciated female patient, with a cutaneous sign of thoracic needle puncture on the right side. Chest opening evidenced blood clots on the parietal pleura and blood collection in the right pleural cavity (total of 1400 mL). The heart was moderately enlarged (450 g), with mild biventricular dilation and an aneurysm formation with thinning of the left lateral myocardial wall (approximately 4x3 cm) (Figure 8). That area evidenced fibrous replacement of the myocardium. The mitral valve showed signs of regurgitation secondary to annulus dilation. In the right chambers, the 593