Intra-abdominal complications of sarcoidosis

Sarcoidosis Mimicking Primary Lung Cancer on 99mTc-3PRGD2 Scintigraphy in a PTC Patient

Sarcoidosis is a multi-system disease of unknown etiology that typically occurs in middle-aged adults, often presenting as the formation of granulomas in various organs, including the lungs. Non-typical pulmonary sarcoidosis is rare, and it isnecessary to distinguish its imaging features from lung cancer and tuberculosis. They may appear as an irregular mass with multiple nodules on thoracic computed tomography (CT). In this case, primary lung cancer was suspected in a 57-year-old papillary thyroid carcinoma patient, as the pulmonary lesions were non-radioiodine avid and progressed shortly afterward. The asymmetrical focal uptake that was demonstrated in integrin receptor imaging (99mTc-PEG4-E[PEG4-c(RGDfK)]2 (99mTc-3PRGD2)) warranted flexible-bronchoscope biopsy. Meanwhile, no evidence of malignancy was found, and pathological manifestations led to the subsequent six months of anti-tuberculosis treatment. Combined with the fact that standard anti-tuberculosis showed no improvement, and the patient’s condition was stabilized by corticosteroid treatment alone, a final diagnosis of sarcoidosis was made by an MDT (multidisciplinary consultation). Reported herein is the first case of a hyper vascularization condition within the non-typical asymmetrical sarcoidosis lesions, which should help to establish that the uptake of 3PRDG2 in sarcoidosis can avoid imaging pitfalls.

Sarcoidosis vs. Colon Cancer Metastasis: Diagnostic Dilemma and the Role of PET Scan in Monitoring Disease Activity

Sarcoidosis is a systemic inflammatory disorder characterized by “noncaseating granulomas.” It primarily affects the lungs, but multiple other organs can be involved. Sarcoidosis has been increasingly reported in association with cancer. It can precede, follow or occur at the same time as the diagnosis of cancer. We report a case of sarcoidosis that was diagnosed concomitantly with colon cancer, highlighting the diagnostic dilemma of sarcoidosis vs. cancer metastasis, the relationship between the two, and the value of PET scan in follow-up and monitoring of disease activity.

Endoscopic and histologic evaluation of the gastrointestinal tract in patients with sarcoidosis

BACKGROUND

The involvement of gastrointestinal tract is rare in sarcoidosis. Endoscopic and histologic evaluation likely provides diagnostic clue in sarcoidosis patients. The aims were to assess the frequency of abnormal endoscopy and histology in patients with sarcoidosis undergoing endoscopic evaluation and to characterize the endoscopic and histologic features in sarcoidosis of the gastrointestinal tract.

METHODS

This was a retrospective study that included 230 patients with a confirmed diagnosis of sarcoidosis in a tertiary care center. The endoscopic and pathology reports were assessed, and serum angiotensin converting enzyme analysis was performed.

RESULTS

Of 230 patients, 63 upper endoscopies and 142 colonoscopies were performed. The most common indication for upper endoscopy was abdominal pain (36.8%) while colonoscopy was most frequently performed for colorectal cancer screening (58.2%). There were 25 upper gastrointestinal biopsies performed (biopsy rate 39.7%) with a diagnostic yield of 92.0% abnormal biopsies, of which the main findings were esophageal tissue eosinophilia, gastritis and duodenal villous blunting. There were 99 lower gastrointestinal biopsies (biopsy rate 64.1%) with a diagnostic yield of 68.7% abnormal biopsies for adenocarcinoma, adenoma, inflammation, low-grade dysplasia, or polyp. Only one gastric biopsy revealed evidence of non-necrotizing granulomas. Of note, patients undergoing esophagogastroduodenoscopy or colonoscopy were more likely to have underlying gastrointestinal comorbidities (62.5%, P < 0.001).

CONCLUSION

Patients with sarcoidosis undergoing endoscopic evaluation have high histologic abnormalities with a low probability of characteristic histologic (i.e. granulomas, Schaumann and asteroid bodies) findings.

A Rare Case of Colonic Sarcoidosis Presenting as a Mass

Introduction

Sarcoidosis is a common multisystem chronic inflammatory disease of an unidentified inciting etiology. The most common initial manifestations of this disease involve the pulmonary system, and involvement of the gastrointestinal tract is rare. Sarcoidosis of the gastrointestinal tract occurs in an oral-anal gradient, with the esophagus and stomach being the most commonly involved sites, while colonic involvement remains extremely rare. Case Presentation. We present a case of a 24-year-old African American man who was evaluated for persistent abdominal pain, chronic diarrhea, and weight loss. Workup for infectious etiologies and celiac disease was unrevealing. An inflammatory mass in the hepatic flexure was found during colonoscopy, and a computed tomography (CT) scan of the abdomen was significant for circumferential thickening of the cecum and ascending colon, along with nodular thickening of the peritoneum without enhancement. Malignancy and inflammatory bowel disease were the initial differentials. A peritoneal biopsy was also performed. Pathology of the colon and peritoneal biopsy was significant for the presence of noncaseating granulomas and confluent granulomatous inflammation. The patient was diagnosed with colonic sarcoidosis, and treatment with corticosteroids was initiated. Symptoms resolved with treatment, and a follow-up colonoscopy five months later showed interval healing.

Conclusion

Although rare, colonic sarcoidosis should be considered as one of the differential diagnoses when evaluating a patient with chronic diarrhea and a mass on colonoscopy. Histopathology is the key to diagnosis as it distinguishes malignancy from sarcoidosis. Corticosteroids remain as an option for treating colonic sarcoidosis.

CT Findings in Pulmonary and Abdominal Sarcoidosis. Implications for Diagnosis and Classification

Sarcoidosis is a granulomatous disorder of unknown etiology characterized by noncaseating granulomas virtually in every organ and tissue. This finding represents the most important diagnostic clue to reach a correct definition of sarcoidosis, although the biopsy is invasive and has several risk procedures. Several efforts are made to suspect the diagnosis of sarcoidosis by combining noninvasive elements, in particular from imaging, though these findings are often nonspecific and reflect the wide multifactorial pathogenesis. Every effort should be made to obtain a detailed radiological picture that, if associated with a suggestive clinical picture, could avoid the need of biopsy in some specific cases. In this narrative review, we aim to describe main computed tomography (CT) features of pulmonary and abdominal sarcoidosis, by reporting strengths and limits of this technique, in particular for the identification of extrapulmonary, isolated disease.

Hepatic sarcoidosis with atypical radiological manifestations: A case report

Sarcoidosis is a multisystemic inflammatory disease of unknown origin characterized by the formation of noncaseating granulomas and accumulation of inflammatory cells. Sarcoidosis most commonly affects the lungs and lymphoid system. However, the liver can also be involved in 50%-65% of cases. On magnetic resonance imaging, sarcoidosis lesions usually present as hypointense lesions on all sequences. However, we present a rare case of nodular liver sarcoidosis presenting with T2 hyperintense lesions. In addition, while most cases of hepatic nodular sarcoidosis present with multiple small hepatic nodules, liver masses of our case are larger than usual. Moreover, this case suggested that when intact vascular structures penetrating liver nodular lesions are observed as in the current case, liver sarcoidosis can be included in a list of differential diagnosis.

Cardiac Sarcoidosis Presenting as Acute Progressive Heart Failure with Abdominal Lymphadenopathy

A 77-year-old Japanese woman presented with asymptomatic abdominal lymphadenopathy. Soluble interleukin-2 receptor (sIL2R) and angiotensin-converting enzyme (ACE) levels were elevated, and a pathological examination of lymph-node biopsies revealed non-caseating granulomas, which was consistent with sarcoidosis. Fluorodeoxyglucose-positron emission tomography did not show a clear accumulation in the mediastinal lymph-nodes or heart. Five months later, she presented with acute progressive heart failure that was refractory to conventional treatment. Her sIL2R and ACE levels decreased spontaneously over time, without steroid treatment. Autopsy findings revealed non-caseating granulomas. Cardiac sarcoidosis presenting as acute, progressive, treatment-refractory heart failure is rare. Steroid therapy after the resolution of inflammation did not affect the clinical outcome.

Abdominal sarcoidosis: cross-sectional imaging findings

Sarcoidosis is a multisystem inflammatory disease of unknown etiology. The lungs and the lymphoid system are the most commonly involved organs. Extrapulmonary involvement is reported in 30% of patients, and the abdomen is the most common extrapulmonary site with a frequency of 50%-70%. Although intra-abdominal sarcoidosis is usually asymptomatic, its presence may affect the prognosis and treatment options. The lesions are less characteristic and may mimick neoplastic or infectious diseases such as lymphoma, diffuse metastasis, and granulomatous inflammation. The liver and spleen are the most common abdominal sites of involvement. Sarcoidosis of the gastrointestinal system, pancreas, and kidneys are extremely rare. Adenopathy which is most commonly found in the porta hepatis, exudative ascites, and multiple granulomatous nodules studding the peritoneum are the reported manifestations of abdominal sarcoidosis. Since abdominal sarcoidosis is less common and long-standing, unrecognized disease can result in significant morbidity and mortality. Imaging contributes to diagnosis and management of intra-abdominal sarcoidosis. In this report we reviewed the cross-sectional imaging findings of hepatobiliary, gastrointestinal, and genitourinary sarcoidosis.

Abdominal Sarcoidosis May Mimic Peritoneal Carcinomatosis

Sarcoidosis is a multisystem inflammatory disorder of unknown etiology. It shows a great variety of clinical presentation, organ involvement, and disease progression. Lungs and lymphoid system are the most common sites involved with a frequency of 90% and 30%, respectively. Extrapulmonary involvement of sarcoidosis is reported in 30% of patients and abdomen is the most frequent site. Furthermore, peritoneal involvement is extremely rare in sarcoidosis. The case presented here described peritoneal manifestations of sarcoidosis without involvement of lungs. A 78-year-old woman possessing signs of malignancy on blood test and abdominal magnetic resonance imaging underwent laparatomy with a suspicion of ovarian malignancy. The macroscopic interpretation during surgery was peritoneal carcinomatosis. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritoneal biopsies, total omentectomy, and appendectomy were performed. Final histopathological result revealed the diagnosis of sarcoidosis. Clinicians must keep in mind that peritoneal sarcoidosis can mimic intra-abdominal malignancies.

Corticosteroid Responsive Sarcoidosis with Multisystemic Involvement Years after Initial Diagnosis: A Lymphoma Mimicker on 18-FDG PET/CT

Sarcoidosis is a chronic multisystemic inflammatory disease characterized by noncaseating epithelioid cell granulomas. 18-Fluorodeoxyglucose positron-emission tomography/computer tomography (FDG-PET/CT) is increasingly used in routine clinical practice to assess active sarcoidosis because it can detect active inflammatory granulomatous disease. However, active sarcoidosis lesions are observed to be hypermetabolic on FDG-PET/CT much like malignancies, which may lead to misinterpretation on imaging. In this case report, we present a rare case of sarcoidosis with multisystem involvement including lung, lymph nodes, bone, pleura, and soft tissue that mimicked lymphoma on FDG-PET/CT and responded to corticosteroid treatment.

CT of Hepatic Sarcoidosis: Small Nodular Lesions Simulating Metastatic Disease

Background

Sarcoidosis is a multisystemic inflammatory disease of unknown origin. The lymphoid system and the lungs are the most commonly involved organs. The frequency of signs or symptoms of hepatic involvement is very low.

Case Report

We present a case of symptomatic granulomatous liver disease secondary to sarcoidosis, mimicking a metastatic disease on ultrasonography and CT.

Conclusions

Hepatic involvement in sarcoidosis might be a perplexing diagnostic problem. The decisive CT finding with respect to the differential diagnosis was the absence of a mass effect and intact vascular architecture around the lesions.

Colonic sarcoidosis: Unusual onset of a systemic disease

Sarcoidosis is a multisystem chronic inflammatory condition of unknown etiology that has the potential to involve every tissue in the body. Sarcoidosis in the gastrointestinal system, and particularly the colon, is very rare. Here, we report the case of a 57-year-old man with no previous diagnosis of sarcoidosis who presented with new onset of abdominal pain and constipation. A colonoscopy revealed that the abdominal pain was caused by an obstructing lesion in the cecum-ascending colon and lacked a clear histologic diagnosis. Radiologic investigation revealed concentric wall thickening of the cecum-ascending colon with multiple satellite lymphadenopathies, highly suggestive of a malignancy. The patient underwent a laparotomy and a right hemicolectomy was performed. A diagnosis of colonic sarcoidosis was made after the resected specimen was examined. Additionally, a chest computed tomography scan revealed lung involvement with atypical radiologic features in the absence of respiratory symptoms. Only histologic examination of the surgical specimen can yield a diagnosis of gastrointestinal sarcoidosis due to the non-specificity of endoscopic and radiologic findings.

[An unusual case of duodenal sarcoidosis]

INTRODUCTION

Sarcoidosis is a systemic granulomatous disorder of unknown aetiology. It may rarely affect the gastrointestinal tract.

CASE REPORT

We reported a 54-year-old woman with a delayed diagnosis of duodenal sarcoidosis. She presented with gastric and right upper abdominal pain associated with vomiting and marked weight loss. Abdominal computed tomographic scan showed non-compressive retroperitoneal lymph nodes and histological examination revealed non-caseating epithelioid granulomas typical of sarcoidosis. Diagnosis of duodenal sarcoidosis was obtained at the third gastroscopy. The patient's condition improved quickly with corticosteroid therapy.

CONCLUSION

Gastrointestinal sarcoidosis should be looked for in patients with digestive symptoms and another sarcoid localisation. Furthermore, it is important to repeat gastroscopy to confirm diagnosis because treatment improved most patients.

Hepatic Sarcoidosis

Sarcoidosis is a multisystem disease characterized by the presence of non-caseating granulomas in affected organs. Pulmonary involvement is the most common site of disease activity. However, hepatic involvement is also common in sarcoidosis, occurring in up to 70% of patients. Most patients with liver involvement are asymptomatic. Therefore, the majority of cases are discovered incidentally, frequently by the finding of elevated liver enzymes. Pain in the right upper quadrant of the abdomen, fatigue, pruritus, and jaundice may be associated with liver involvement. Portal hypertension and cirrhosis are complications linked to long-standing hepatic sarcoidosis. Liver biopsy is usually required to confirm the diagnosis. It is important to differentiate hepatic sarcoidosis from other autoimmune and granulomatous liver diseases. Not all cases of hepatic sarcoidosis require treatment. For symptomatic patients, the first line treatment includes corticosteroids or ursodeoxycholic acid. Various immunosuppressant agents can be used as second line agents. Rarely, severe cases require liver transplantation.

Unusual presentation of a colonic sarcoidosis

Sarcoidosis is a multisystemic disorder of unknown cause that affects almost every tissue in the body. Colon is an extremely rare location of this disease. Clinical presentation, endoscopic appearances, and radiologic findings are not specific and may mimic much other affection. We report the case of a 64-year-old woman with inactive pulmonary sarcoidosis who presented alternating constipation and diarrhea. Colonoscopy revealed a stenotic tumor in the ascending colon. Histology failed to determine the nature of the lesion. Radiologic findings are those of a long stenotic tumor of the ascending colon associated with a multiple satellite lymphadenopathy. Endoscopic and radiologic descriptions are highly suggestive of a malignancy. The patient underwent a laparotomy, and a right hemicolectomy was performed. Examination of the resected specimen showed follicular structure with central epitheloid and giant cells and surrounding fibroblasts. These findings made the diagnosis of colonic sarcoidosis. The nonspecificity of the endoscopic and radiological signs of gastrointestinal sarcoidosis and the extreme rarity of colonic location make the preoperative diagnosis unlikely. The diagnosis will be then made only on histological examination of surgical specimens. We describe, through this observation, the results of paraclinical investigations that can suggest diagnosis and perhaps avoid surgery.

Extra-pulmonary manifestations of sarcoidosis

Although, the diagnosis and evaluation of sarcoidosis has traditionally remained confined to the chest, its multi-system nature has been widely recognized. Radiological features of pulmonary sarcoidosis are well known but extra-pulmonary manifestations can produce a plethora of non-specific imaging findings that can affect subcutaneous tissue, and the neurological, cardiac, gastrointestinal, urological, liver, spleen, and skeletal systems. In the literature, there are various case reports and specific system reviews but there are few reviews that encompass all the extra-pulmonary manifestations. In this paper, we comprehensively review the imaging features of extra-pulmonary sarcoidosis with characteristic features as well as atypical presentations. In addition, we discuss the emerging role of nuclear medicine in sarcoidosis.