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Chagas cardiomyopathy (CC) and cardiac sarcoid (CS) can both present with heart failure (HF) and arrhythmias. Differentiating between these two entities may be difficult without pathological analysis. We present a case of a man with new onset HF and atrial fibrillation who was diagnosed with CS after cMRI and PET/CT imaging. The patient eventually underwent heart transplantation and histopathological analysis of the explant and further serological testing confirmed diagnosis of CC. A 47-year-old man from El Salvador presented with and shortness of breath and orthopnea for two months. TTE showed dilated biventricular HF with EF of 15% and LVIDd 7.1 cm. Telemetry revealed episodes of atrial fibrillation. Coronary angiogram showed nonobstructive disease. CMRI revealed late gadolinium enhancement of the thinned lateral wall with marked wall motion abnormality. These findings made CS a possibility, so a cardiac FDG PET/CT was done. This showed diffusely increased, heterogeneous FDG activity compatible with active inflammation and a few small minimally FDG-avid bilateral mediastinal lymph nodes. High resolution chest CT did not find lymphadenopathy or lung pathology. The diagnosis of likely CS was made, and he was started on steroids and later adalimumab. Two years later he was readmitted with ventricular tachycardia and cardiogenic shock. He was listed for transplant urgently and placed on an IABP until he was transplanted. His explant showed interstitial chronic inflammation with lymphocytes, plasma cells and eosinophil and myocyte necrosis. (Figure 1) No granulomas or giant cells were seen, making CS unlikely. Specimens sent prior to transplant showed positive Trypanosoma Cruzi IgG and PCR suggesting CC. Our case demonstrates the diagnostic challenges in differentiating between CC and CS. Clinical and imaging findings may be similar, thus biopsy evaluation should be undertaken to make the right diagnosis. [ABSTRACT FROM AUTHOR]