case report

Anaesthetic Management of a Patient with Sarcoidosis Presenting for Mastectomy
Rachel Cherian Koshy, Rajasree, Mary Thomas
Sarcoidosis is a rare condition, the reported incidence being
1-64 per 100000 population worldwide.1 There are anecdotal
reports of serious cardiac, pulmonary and airway problems
in patients with sarcoidosis undergoing surgical procedures
under anaesthesia.
CASE REPORT
A 48 year lady with sarcoidosis presented for mastectomy
for carcinoma breast. Prior to two years, she had
experienced difficulty in breathing even while carrying out
a conversation. A biopsy of cervical lymph node revealed
her disease to be sarcoidosis. She was treated with oral
steroids for a year, which improved her symptoms.
The patient became hypertensive since one year. She
was on Tab bisoprolol 2.5 mg and hydrochlorthiazide 6.25
mg once daily. She weighed 71kg, her blood pressure was
130/80 mm Hg and heart rate 68/minute. Her airway
examination showed a mouth opening of 5 cms, thryomental
distance of 3 fingers and Mallampatti Class 2. Both heart
sounds were normal with no added sounds. Chest was
clear and air entry equal bilaterally. Physical examination
revealed lumps in both breasts. Hematological & biochemical
investigations were all within normal limits. Chest X-ray PA
view showed calcified node in the right hilum. There was
no cardiomegaly. ECG showed sinus rhythm with a heart
rate of 70/minute, PR interval 0.16 sec and no significant
ST-T changes. Echo cardiograph showed normal sized heart
chambers and valves with good LV function and no wall
motion abnormality. A tricuspid regurgitation of 27mm Hg
was present. Pulmonary function test showed mild restriction
with FEV1 94% of predicted & FVC 90% of predicted, FEV1/
FVC ratio of 104. CT study of chest and abdomen did not
reveal any abnormality except the calcified node in right
hilum of lung.
The patient was premedicated with Tab Diazepam
10mg, Pantoprazole 40mg on the night before and 6.00 am
on day of surgery. In addition she was given inhaled
bronchodilators and Inj Hydrocortisone 100mg intravenously
an hour before induction of anaesthesia.
In the OR, monitoring of ECG, pulse oximetry, NIBP
was instituted. She was given Inj Midazolam 1mg and
Fentanyl 80mcg intravenously. This was followed by
Drs. Rachel Cherian Koshy, Additional Professor and Head, Rajasree, Post Graduate Trainee, Mary Thomas, Associate
Professor, Department of Anaesthesiology, Regional Cancer Centre, Trivandrum 695 011, Kerala, India.
Correspondence: Dr. Rachel Cherian Koshy, E-mail: rachelrcc@yahoo.co.in
precurarisation with 5 mg Atracurium and induction with
100mg Propofol and 100mg succinylcholine. Endotracheal
intubation was performed with size 7mm ID cuffed oral
endotracheal tube and cuff inflated with 6ml air. Patient was
connected to an anaesthesia work station and ventilated
with 1 % halothane in a mixture of air and oxygen with an
FiO2 of 0.35. A low dose propofol infusion was also started.
Vital parameters (heart rate, BP, ECG, SpO2, ETCO2, were
all kept stable and maintained throughout the surgical
procedure (left mastectomy and wide excision of lump right
breast) Muscle relaxation was achieved with Atracurium
45mg iv. At the end of surgery which lasted for 150 minutes,
neuromuscular blockade was reversed with Inj. Neostigmine
2.5mg and Atropine 1.2mg. Diclofenac 100mg was given
as rectal suppository. The patient recovered completely and
was awake with mild pain which was relieved in about 15
minutes. Post operative pain relief was achieved with
intravenous Injection Tramadol 50mg 6th hourly. The post
operative period was uneventful.
DISCUSSION
Sarcoidosis is an idiopathic multisystem granulomatous
disorder occurring commonly in the age group of 20-40
years with a slight preponderance in females.1 Sarcoidosis
results from an exaggerated cell mediated immune response
which can be inherited, acquired, or both.
The organ most frequently affected is the lung followed
by lymph nodes. Other organs such as skin, eye and liver
could also be affected. Sarcoidosis favours nonsmokers. In
the lung, the inflammatory cells and granulomas distort the
walls of the alveoli, bronchi and blood vessels.
Approximately 50% patients develop permanent pulmonary
abnormalities and 5-15% have progressive fibrosis of the
lung. There is an interstitial lung disease which presents
with dyspnea on exercise and dry cough with rales in the
lung fields on examination. Endobronchial sarcoidosis can
produce distal atelectasis. Large vessel pulmonary
granulomatous arteritis is common. Pleural involvement
occurs in 1 to 5% cases as unilateral pleural effusion.1 Cor
pulmonale may develop owing to sarcoidosis.
Intrathoracic lymphadenopathy occurs in 75 to 90% of
all patients. The most commonly involved are hilar and
J Anaesth Clin Pharmacol 2010; 26(4): 555-556
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paratracheal nodes. Subcarinal, mediastinal nodes may
also involved. Nasal mucosal involvement occurs in 20%
patients who present with nasal stuffiness. Laryngeal
involvement occurs in 1-5% of cases. These individuals
have hoarseness of voice, dyspnea, wheeze and stridor.
Hypercalcaemia occurs in 1-2% cases.2 Neurologic findings
are observed in 5% of patients. Seventh nerve involvement
with unilateral facial paralysis is most common.3 The
hypothalamo- pituitary axis is involved and the condition
presents as diabetes insipidus. Nearly 5% of patients have
significant heart involvement with clinical evidence of cardiac
dysfunction. Arrhythmias and conduction disturbances can
occur. Papillary muscle dysfunction, pericarditis, CCF is
also observed. Myocardial sarcoidosis although rare may
manifest as heart block, cardiac arrythmias or restrictive
cardiomyopathy.2,4
Chest radiograph could show bilateral hilar adenopathy
with or without parenchymal changes and "ground glass
appearance" consistent with active alveolitis is seen on CT
scan.
Lung function tests show decrease lung volumes,
decreased diffusing capacity and normal or increased ratio
of FEV1/FVC. The therapy of choice is glucocorticoids. Initial
dose of prednisone is 20 to 40 mg /day for less than two
years.
Sarcoidosis appears to be associated with increased
risk for cancer in affected organs.5,6,7 This may be secondary
to immunological abnormalities associated with sarcoidosis8
Sarcoidosis may be improved or exacerbated by pregnancy.9
Anaesthetic problems in patients with sarcoidosis
Laryngeal involvement and tracheal stenosis may interfere
with passage of appropriate sized adult endotracheal tube.3,8
Stenosis of trachea and bronchi as a result of sarcoidosis
and symptomatic improvement following dilatation with
Fogarty catheter has been described.10
Anaesthesia may contribute to precipitating heart block
in a patient with sarcoidosis as is described in the case
report of a fit young man with sarcoidosis who developed
complete heart block during emergency mastoidectomy. The
case was managed with temporary transvenous pacemaker
and later insertion of permanent pacemaker11 Cardiac
sarcoidosis is a dreaded condition where left ventricular
dysfunction manifested as severe reduction in ejection
fraction and myocardial conduction defects occur. Cases of
sudden death during stable cardiac function have been
reported.4
In our case anaesthesia did not result in any additional
morbidity or problems.
In conclusion it is prudent to be prepared for cardiac
events, difficult intubation and respiratory compromise in
patients with known sarcoidosis.