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A 45‐year‐old man presented to the emergency room after three syncopes. ECG showed sinus rhythm with complete right bundle branch block and left anterior fascicle block. Echocardiography and 24 h ECG monitoring were normal. Chest radiography showed small patchy infiltrations and spiro‐ergometry tests showed normal carbon monoxide transfer factor but a reduction in physical capacity (maximum oxygen consumption 70%) associated with an effort‐related grade II atrioventricular block. An MRI scan of the heart using gadolinium showed enhancement at the anteroseptal level (fig 1A1A),), and 18F‐FDG positron emission tomography (PET) showed focal uptake at exactly the same location (fig 1B1B).). Transbronchial biopsy specimens showed typical granulomas and bronchoalveolar lavage revealed lymphocytosis of 26% and a CD4/CD8 quotient of 7.5, both compatible with sarcoidosis.
A DDD pacemaker was implanted and steroid treatment was started. Since MRI was no longer feasible because of the pacemaker, an 18F‐FDG PET scan was performed at 3 months follow‐up (fig 1C1C)) which showed complete disappearance of the focal uptake. These changes correlated with disappearance of the chest radiographic findings and recovery from the grade II effort‐dependent atrioventricular block with an increase in maximum oxygen consumption from 24.9 to 33.3 ml/kg/min.