Role of infliximab in managing resistant ventricular arrhythmias in sarcoidosis

Introduction: Five percent of sarcoid patients have cardiac involvement; many of these get ventricular tachyarrhythmias (VT) which can be difficult to treat. Infliximab is efficacious in sarcoid but its role in managing VT in cardiac sarcoid is not clear. Aim: We present a case of a 56 year old lady with multi-system sarcoid and resistant VT. Case: The patient was known to have pulmonary and ocular sarcoid with the diagnosis confirmed on a transbronchial biopsy. She developed VT in 2008. Cardiac MRI showed patchy epicardial-mid wall delayed gadolinium enhancement suggestive of cardiac sarcoid. The patient was cardioverted and started on prednisolone. An ICD was implanted after a second admission with VT in 2010. She started mycophenolate, which was changed to Azathioprine due to side effects. Radiofrequency ablation was performed in 2012, with reduction in the burden of VT. The patient continued to have recurrent ventricular fibrillation despite being on bisoprolol, amiodarone, mexiletine, azathioprine and prednisolone. She was commenced on cyclical infliximab in Nov 2013, and since then has not had any arrhythmias. Discussion: The role of Infliximab in the treatment of tachy-arrhythmias in cardiac sarcoid is unclear. Two reports describe the resolution of heart block with this therapy 1,2 . Only one report describes successful cessation of VT with inlfiximab in the setting of multi-system sarcoid 3 . Our case illustrates that infliximab has a role in treating resistant ventricular arrhythmias in cardiac sarcoidosis. References: 1 Barnabe C. et al. The Journal of Rheumatology 2008; 35(8):1686. 2 Uthman I.et al. Clinical Rheumatology 2007;26:2001-03. 3 Roberts S.D. et al. Chest 2003; 124 (5) : 2028-31.