Discordant myocardial perfusion defects and coronary artery disease – a multimodality imaging journey in the natural history of cardiac sarcoidosis

Cardiac sarcoidosis is a rare form of systemic sarcoidosis characterized by formation of non-caseating granulomas in the myocardium, leading to heterogeneous manifestations, including conduction disturbances, arrhythmias, and heart failure. Besides myocardial fibrosis and structural myocardial alterations, cardiac sarcoidosis can impact the epicardial and microvascular circulation, causing ischemia and regional microvascular dysfunction. We present a case of cardiac sarcoidosis with atypical initial presentation but with evidence of disease in myocardial perfusion imaging, which was overlooked since it did not correspond to bystander coronary artery disease. Multimodality imaging facilitated diagnosis and offered insights into the regional microcirculation impairment caused by sarcoidosis-induced inflammation.