Laparoscopic Splenectomy for Isolated Sarcoidosis of the Spleen

Sarcoidosis presenting as isolated massive splenomegaly: A case report

Key Clinical Message

Sarcoidosis is a systemic granulomatous disease with an unknown cause, marked by the presence of noncaseating granulomas in the affected organs. While the pulmonary interstitium is most frequently involved, the disease can affect almost any other organ system. Extrapulmonary involvement can occur with or without lung involvement, but isolated extrapulmonary involvement is a rare event. Isolated splenomegaly is very rare and presents an uncommon manifestation of sarcoidosis, its diagnoses is a challenge due to a broad differential diagnosis. Here, we present an intriguing case of a 28-year-old male with isolated splenic sarcoidosis.

Abstract

Sarcoidosis is a systemic disease of unknown cause, marked by the presence of noncaseating granulomas in affected organs. It most frequently impacts the pulmonary interstitium, though it can also affect nearly any other organ system. This involvement can occur with or without lung involvement, but isolated extrapulmonary cases are observed in only about 10% of instances. Furthermore, isolated splenomegaly is an exceptionally rare event and an uncommon presentation of sarcoidosis, posing a significant clinical challenge due to the wide differential diagnosis. Potential differential diagnoses include hematologic cancers, primary or metastatic splenic tumors, infiltrative diseases, inflammatory conditions, and infections. We present a noteworthy case of a 28-year-old with isolated splenic sarcoidosis.

A Pesky Spleen: A Painful Presentation of Extrapulmonary Sarcoidosis

Sarcoidosis is an inflammatory and granulomatous disease of uncertain etiology that can impact various organ systems and exhibits diverse clinical presentations, which adds to the complexity of disease diagnosis and management. Pathologically, it is distinguished by the presence of noncaseating granulomas within the affected organ system. In this case report, we describe a 34-year-old Caucasian female patient with isolated splenic and possible hepatic involvement of sarcoidosis, presenting with severe abdominal pain. The absence of the typical pulmonary, cutaneous, or joint involvement posed challenges in achieving a definitive diagnosis and determining the appropriate management. Imaging studies revealed hepatic and splenic hypodensities, necessitating consideration of various differential diagnoses, including lymphoproliferative disorders, immunological disorders, environmental particle exposure, infectious causes, neoplasms, and drug reactions. The severity of symptoms in this case required hospital admission for pain and nausea control, biopsy, and eventual splenectomy with pathology that confirmed the diagnosis of splenic sarcoidosis.

Two Cases with Isolated Splenic Sarcoidosis Diagnosed by an Ultrasound-guided Fine-needle Aspiration Biopsy

Asymptomatic splenic nodules were detected incidentally in two middle-aged women at an annual checkup. They showed no abnormalities on laboratory tests, but imaging studies revealed splenic nodules. No other localized lesions were found. Splenic nodules were hypoechoic on ultrasonography (US), hypovascular on contrast-enhanced computed tomography, and showed a low intensity on T2-weighted magnetic resonance imaging. We performed US-guided percutaneous aspiration biopsies using 21-gauge needles without complications, including bleeding. Pathological specimens showed noncaseating granulomas, so both patients were diagnosed with isolated splenic sarcoidosis. A US-guided fine-needle aspiration biopsy is a safe and useful method for diagnosing splenic nodules.

Isolated splenic sarcoidosis: a rare cause of hypercalcaemia in a patient with type 1 diabetes

A 30-year-old man was admitted to Intensive Therapy Unit (ITU) with status epilepticus secondary to severe hypoglycaemia on a background of type 1 diabetes. CT of the brain showed generalised cerebral oedema. He was successfully stepped down to a medical ward after 2 weeks. He was noted to have persistently high calcium, which required multiple doses of pamidronate. Parathyroid hormone level was appropriately low. CT of the thorax, abdomen and pelvis showed mild hepatosplenomegaly with small pathological lymph nodes throughout the abdomen. Bone marrow biopsy was unremarkable. Lymph node biopsy was difficult to achieve, and therefore a positron emission tomography scan was arranged. This showed an enlarged and hypermetabolic spleen. Differential diagnoses at this point included lymphoma and sarcoidosis. He underwent diagnostic splenectomy, and the diagnosis of sarcoidosis was confirmed histologically. Calcium level remained normal 17 months after splenectomy.

Symptomatic isolated axillary lymph node sarcoidosis: an unusual presentation

An 82-year-old woman admitted following a 4-week history of feeling unwell, abdominal pain and constipation. Initial investigations revealed severe hypercalcaemia with suppressed parathyroid hormone and elevated 1,25-dihydroxycholecalciferol. ACE was also raised. CT scans of the head, chest, abdomen and pelvis were normal. Fluorodeoxyglucose-positron emission tomography scan showed metabolically active right axillary lymphadenopathy which when biopsied under ultrasound guidance confirmed sarcoidosis. The patient was started on high-dose prednisolone with resolution of symptoms within 2 weeks. Isolated lymph node sarcoidosis is uncommon, and the reported usual sites are lymph nodes in the head and neck. Rarely has it been reported in the axillary lymph nodes.

Laparoscopic splenectomy for isolated splenic sarcoidosis: A case report

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Isolated splenic sarcoidosis is difficult to diagnose due to its rarity.

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Laparoscopic splenectomy has become the gold standard in patients presenting with solid splenic lesions.

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Laparoscopic splenectomy is less invasive and useful as part of the diagnostic approach.

Introduction

Isolated splenic sarcoidosis is difficult to diagnosis due to its rarity. Laparoscopic splenectomy has become the gold standard for therapeutic diagnosis in patients presenting with solid splenic lesions because needle biopsy can lead to bleeding and tract seeding.

Presentation of case

A 59-year-old female was referred to our hospital due to abnormal accumulation in the spleen on abdominal ultrasonography. Enhanced computed tomography showed three heterogeneously enhanced nodules. Magnetic resonance imaging showed hypointense nodules on T2-weighted images. The initial diagnosis was a fibrous hamartoma or an inflammatory pseudotumor. At follow-up 4 months later, the splenic nodules had increased in size, and diagnostic laparoscopic splenectomy was performed without complications. Histopathologically, the splenic nodules contained noncaseating granulomas comprising epithelioid cells, multinucleated giant cells, and asteroid inclusion bodies. Postoperatively, examinations found no other organ involvement, and the final diagnosis was isolated splenic sarcoidosis. There was no evidence of recurrence at 2 years postoperatively, and systemic treatment was not required.

Conclusion

Radiological imaging studies are insufficient for the differential diagnosis of splenic lesions in sarcoidosis from other diseases, whereas laparoscopic splenectomy is less invasive and useful as part of the diagnostic approach.

Sarcoidosis and Its Splenic Wonder: A Rare Case of Isolated Splenic Sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown etiology characterized by presence of noncaseating granulomas in the involved organs. The pulmonary interstitium is most commonly affected but extrapulmonary involvement can occur in almost any other organ system. Such an involvement can occur with or without the presence of pulmonary involvement, but isolated extrapulmonary involvement has been noted only in around 10% of cases. Isolated splenomegaly is very rare and an uncommon presentation of sarcoidosis. It is clinically challenging because of the extensive differential diagnosis. Among the many considerations are hematologic malignancies, primary splenic or metastatic tumors, infiltrative disorders, inflammatory disorders, and infections. We hereby discuss an interesting case of a 40-year-old female with isolated splenic sarcoidosis.

A case of sarcoidosis with isolated hepatosplenic onset and development of inflammatory bowel disease during recovery stage

Sarcoidosis is a systemic disease characterized by an immune-mediated disorder, which leads to the development of non-caseating granulomas in the involved organs. More than 90% of patients with sarcoidosis present lungs and lymphatic system involvement at onset, while less than 10% has an isolated extrapulmonary localization. Here, we describe the case of an elderly patient with isolated hepato-splenic onset (multiple splenic lesions at imaging and cholestasis), and subsequent pulmonary involvement. The liver biopsy showed the presence of non-caseating granulomas, suggesting sarcoidosis. Despite the complete recovery was obtained with steroid therapy, after dosage reduction the patient presented watery diarrhea. Endoscopic investigations with biopsies were performed, describing the presence of an important lympho-plasmacytic infiltrate of terminal ileum mucosa with typical aspects of inflammatory bowel disease. The symptomatology completely disappeared after steroid dosage increase. This case confirms that sarcoidosis could present in a very atypical way, involving several organs in a different manner at the same time and that every symptom should not be underestimated, despite the rare presentation.

Unusual Presentation Of Sarcoidosis: Case Report

Sarcoidosis is a multisystem granulomatous disease with polymorphic manifestations, of unknown etiology, that can affect any organ in the body, but most commonly the lungs [1,2,3]. Extrapulmonary involvement is common, can occur in association with or in the absence of intrathoracic disease, and all organs can be involved, but it is rare to find an isolated extrapulmonary disease (less than 10% of patients) [3,4]. On occasion, the presentation of sarcoidosis may be atypical.

We report a case of systemic sarcoidosis, with particular clinical data: extrathoracic onset with subdiaphragmatic lymph nodes, hepatomegaly and splenomegaly.

Isolated sarcoidosis of accessory spleen in the greater omentum: A case report

Sarcoidosis is a multisystemic disease of unknown origin characterized by the formation of non-caseating granulomas. Thoracic involvement is the most common presentation; however, sarcoidosis can involve almost any other organ. To the best of our knowledge there have been only 10 cases of splenic sarcoidosis reported in the English literature, with no reports of sarcoidosis of an accessory spleen. The present study reports a case of isolated sarcoidosis of an accessory spleen in the greater omentum, which was identified postoperatively in a 44-year-old female. Chest X-ray results were normal. Gastric endoscopy demonstrated an ulcer in the antrum, which was confirmed to be a signet-ring cell carcinoma via biopsy. Computed tomography of the abdomen revealed mild thickening of the posterior antrum, and a mass in the inferior pole of the left kidney. Intraoperatively, no masses were detected in the liver and spleen. Moreover, no enlarged lymph nodes were detected in the abdominal cavity, pelvic cavity, mesenteric and para-aorta. Following a radical distal gastrectomy and left radical nephrectomy, postoperative pathology demonstrated signet-ring cell carcinoma in the antrum, left renal clear cell cancer and a red lesion measuring 0.5×0.5 cm in the greater omentum, which was similar to the spleen in the splenic cavity and was regarded as an accessory spleen. Following exclusion of fungi and acid-fast bacilli as causative agents, sarcoidosis of the accessory spleen in the greater omentum was confirmed. The patient recovered uneventfully and was discharged on day 8 postoperation. The patient remained alive after two-year follow-up without sarcoidosis and malignant tumor recurrence. The present case demonstrated that, intraoperatively, comprehensive exploration should be conducted to exclude the accessory spleen, which may also suffer from sarcoidosis.

Laparoscopic splenectomy for isolated splenic sarcoidosis

Isolated splenic sarcoidosis is a rare manifestation of extrapulmonary disease and may be amenable to minimally invasive surgical technique.

Introduction:

Sarcoidosis is an inflammatory disease with an unknown etiology. The pulmonary interstitium is mainly involved, with noncaseating granulomas and lymphadenopathy. It is a multisystemic disease, and the differential diagnosis should include infectious, neoplastic, and autoimmune diseases to prevent inappropriate treatment and unnecessary surgery. Abdominal disease without evidence of pulmonary abnormalities on chest radiography in sarcoidosis can be found in approximately 25% to 38% of cases.

The approach to isolated splenic nodules in a patient with nonspecific abdominal symptoms should be focused on exclusion of malignancies and infections, and may require computed tomography, magnetic resonance imaging, and positron emission tomography–computed tomography imaging; scintigraphy; bone marrow biopsy; breast and genital examinations; and endoscopies.

This report documents a rare case of isolated granulomatous disease of the spleen that was diagnosed and treated laparoscopically.

Case:

A 29-year-old woman presented with nonspecific complaints such as nausea, vomiting, and epigastric discomfort. Further laboratory test results were normal. Abdominal ultrasonography, computed tomography, and magnetic resonance imaging revealed multiple splenic lesions. Additional examination findings were negative for occult neoplasia or infectious disease. Laparoscopic splenectomy was performed as a diagnostic procedure, without complications, and the final diagnosis was sarcoidosis.

Conclusion:

Isolated splenic sarcoidosis is a rare manifestation of extrapulmonary disease. The final diagnosis may be achieved only by histology, requiring biopsy or splenectomy. Minimally invasive surgery is a safe and efficient method for diseases of the spleen and should be the first option when feasible. The patient did well; however, further monitoring is required to diagnose recurrence.

Late development of splenic sarcoidosis-like lesions in a patient with metastatic melanoma and long-lasting clinical response to ipilimumab

A male patient with Stage IV melanoma was treated with ipilimumab resulting in a long-lasting partial response according to RECIST criteria. However, twenty months after ipilimumab treatment, routine follow-up CT scan revealed new splenic lesions initially interpreted as indicative of progressive disease. Nevertheless, a biopsy was performed and histologic evaluation showed that the lesions did not contain malignant cells but rather constituted non-caseating epithelioid cell granulomas consistent with sarcoidosis. As the patient was asymptomatic no treatment was initiated and over the following months the splenic lesions slowly disappeared and to date the patient remains in remission. Ipilimumab is now widely used in the treatment of melanoma patients. Our case-report illustrates that physicians should consider the possibility of ipilimumab induced visceral sarcoidosis-like reactions, mimicking metastatic lesions, developing even many months after ipilimumab treatment. Thus, biopsy of such suspicious lesions is advisable to avoid misinterpretation as disease progression and unnecessary resumption of cancer therapy.

A case of severe 1,25-dihydroxyvitamin D-mediated hypercalcemia due to a granulomatous disorder

BACKGROUND

Profound hypercalcemia is usually due to underlying malignancy.

CASE

We describe a case of granulomatous myositis presenting with extreme hypercalcemia of 20.1 mg/dl and generalized weakness that did not resolve despite rapid correction of serum calcium. The disease process was unmasked by cholecalciferol supplementation. Initial search for a malignant process yielded no diagnosis, but an elevated 1,25-dihydroxyvitamin D level, in the setting of a suppressed PTH and undetectable PTHrP, pointed to the presence of excessive 1α-hydroxylase activity.

METHODS AND RESULTS

Biopsy of the vastus lateralis muscle showed extensive granulomatous myositis. Immunohistochemical staining for 1α-hydroxylase was localized to the multinucleated giant cells and histiocytes. Musculoskeletal magnetic resonance imaging showed involvement of proximal muscle groups of both thighs and upper limbs.

CONCLUSION

Measurement of vitamin D metabolites is pivotal in diagnosing 1,25-dihydroxyvitamin D-mediated hypercalcemia. Granulomatous disease can occasionally cause profound hypercalcemia and needs to be considered in the differential diagnosis. 1,25-Dihydroxyvitamin D-mediated hypercalcemia is responsive to glucocorticoid therapy.

Intra-abdominal complications of sarcoidosis

Sarcoidosis is an inflammatory disease characterized by non-caseating granulomas in the absence of other autoimmune processes, infectious diseases, or foreign agents. The etiology of sarcoidosis is not completely understood. Several organ systems can be affected, of which the most frequently involved include the lungs and lymph nodes. Intra-abdominal sarcoidosis is less common, but can be found in the absence of pulmonary or lymphatic disease. Intra-abdominal sarcoidosis is most often asymptomatic. However, long-standing unrecognized disease can result in life-threatening complications. The identification, monitoring and prevention of these complications will be discussed, with emphasis on both clinical and histological presentations of intra-abdominal sarcoidosis.

Hypoglycemia due to ectopic secretion of insulin-like growth factor-I in a patient with an isolated sarcoidosis of the spleen

Hypoglycemia is reported to be one of the manifestations of a patient with hypothalamic sarcoid infiltrates due to impaired counter-regulation of glucose. But, without hypothalamic lesion, patients with sarcoidosis would not be expected to have hypoglycemia. We recently identified a patient with an isolated sarcoidosis of the spleen who had experienced frequent fasting hypoglycemia which completely disappeared after splenectomy. During hypoglycemia, serum insulin was undetectable. Endocrinological examination revealed no abnormality. The objective was to investigate whether the patient's hypoglycemia was due to ectopic secretion of an insulin-mimetic factor by the splenic sarcoidosis. Serum insulin-like growth factor-I (IGF-I) and IGF-II were measured by RIA. Serum visfatin and free IGF-I were by ELISA. A high molecular weight form of IGF-II, termed "big" IGF-II, was identified by Western blotting. Tissue IGF-I was quantified by real time RT-PCR after RNA extraction. Before operation, total and free serum IGF-I, serum IGF-II and serum visfatin were within reference range. Big IGF-II was not detected in patient's serum extract. After operation, hypoglycemia did not recur and serum insulin returned to normal, while serum IGF-I decreased by half the preoperative level. RT-PCR revealed that mRNA level of IGF-I in the sarcoidosis tissue was about 1.8-fold greater than that in the normal spleen tissue. These data suggest that ectopic secretion of IGF-I by the splenic sarcoidosis and its direct access to the liver via the portal vein might cause fasting hypoglycemia mainly by suppressing hepatic gluconeogenesis.

'Surgical cure' for non-parathyroid hypercalcemia

BACKGROUND

Sarcoidosis is a granulomatous disease of unknown aetiology. Over 90% patients of sarcoidosis present with pulmonary findings. Other organs such as lymph nodes, skin, and joints may be involved. Isolated granulomatous disease confined to the spleen is rare.

CASE PRESENTATION

This report documents a rare case of isolated granulomatous disease of spleen presenting as hypercalcemia. After all possible causes for hypercalcemia were ruled out, splenectomy was done which proved diagnostic and therapeutic, as calcium levels returned to normal.

CONCLUSION

We propose that sarcoidosis should be kept in mind as a cause of unexplained hypercalcemia. Increased awareness of radiological features of splenic involvement in sarcoidosis, would help in diagnosis. We believe that we are reporting 9th case in the literature while writing this report.

Splenic peliosis with spontaneous splenic rupture: report of two cases

Background

Peliosis is a rare condition characterised by multiple cyst-like, blood-filled cavities within the parenchyma of solid organs. Most commonly affecting the liver, isolated splenic peliosis is an even more unique phenomenon. Patients with the condition are often asymptomatic. However, this potentially lethal condition can present with spontaneous organ rupture. We present two such cases, discuss their management and review what is currently known in the existing literature.

Case presentation

A previously well twenty-six year old woman presented with abdominal pain following a trivial episode of coughing. A diagnosis of spontaneous splenic rupture was made following clinical and radiological examination. She underwent emergency splenectomy and made a full, uneventful recovery. Histopathological examination confirmed splenic peliosis.

The second case describes an eighty six year old lady who sustained a trivial fall and developed pain in her left side. A CT confirmed splenic rupture. She became haemodynamically unstable during her admission and underwent emergency splenectomy. Histopathological examination revealed splenic peliosis. She went on to make an uneventful recovery.

Conclusion

Splenic peliosis is very rare. It has a number of associations including immunosuppression, drug therapy and infection. Although patients are often asymptomatic, life-threatening spontaneous organ rupture may occur. If the diagnosis of peliosis is confirmed, additional investigations should be considered to detect its presence in other organs. Furthermore, the presence of the condition may be relevant if further medical or surgical intervention is planned.