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Suzuki T, Hayakawa Y, Kaneko S, Takenaka K, Watakabe K, Kinowaki Y, Takemoto A, Ohtsuka K, Asahina Y, Okamoto R. Granulomatous hepatitis with Crohn's disease: a case report. Clin J Gastroenterol 2024; 17:551-556. [PMID: 38502473 DOI: 10.1007/s12328-024-01937-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 02/07/2024] [Indexed: 03/21/2024]
Abstract
A 45-year-old man who was regularly followed up for Crohn's disease (CD) and maintained clinical remission with vedolizumab (VDZ). At 37 years old, he was diagnosed CD from longitudinal ulcers in the distal ileum by balloon-assisted enteroscopy (BAE). During the follow-up, liver enzyme elevation, splenomegaly and thrombocytopenia were in progress. Esophagogastric varices suggested chronic liver disease and portal hypertension. Magnetic resonance elastography (MRE) showed liver stiffness of 3.4 kPa and proton density fat fraction (PDFF) of 1.86%. He was diagnosed with granulomatous hepatitis based on a liver biopsy. The hepatic venous pressure gradient (HVPG) was mildly elevated at 7 mmHg, consistent with the pre-sinusoidal portal hypertension due to granulomatous hepatitis. We report a rare case with granulomatous hepatitis diagnosed from liver injury and portal hypertension, despite the stable intestinal symptoms of CD.
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Affiliation(s)
- Tatsuya Suzuki
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Yuka Hayakawa
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Shun Kaneko
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan.
| | - Kento Takenaka
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Keiya Watakabe
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
| | - Yuko Kinowaki
- Department of Comprehensive Pathology, Graduate School of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Akira Takemoto
- Bioresource Research Center, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kazuo Ohtsuka
- Endoscopic Unit, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Yasuhiro Asahina
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
- Department of Liver Disease Control, Tokyo Medical and Dental University, Tokyo, Japan
| | - Ryuichi Okamoto
- Department of Gastroenterology and Hepatology, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-Ku, Tokyo, 113-8519, Japan
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Genta RM, Rugge M. Host-related low-prevalence gastritides: Epidemiological and clinical characterization. Dig Liver Dis 2024:S1590-8658(24)00714-X. [PMID: 38705782 DOI: 10.1016/j.dld.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 04/15/2024] [Accepted: 04/15/2024] [Indexed: 05/07/2024]
Abstract
INTRODUCTION A recent consensus meeting (RE.GA.IN) addressed "host-related, low-prevalence gastritis": eosinophilic (EoG), lymphocytic (Hp-pos_LyG and Hp-neg_LyG), collagenous (CollG), and granulomatous gastritis (GrG). Our study evaluates their clinico-epidemiological characteristics. MATERIALS AND METHODS We extracted all patients with a diagnosis of EoG, LyG, CollG, and GrG from a clinicopathological database and compared their demographics, clinical and endoscopic characteristics, associated conditions, and clinical awareness to those of all other subjects in the database (controls). RESULTS There were 1,781,005 unique patients (median age 57 years; 55.7 % female). Hispanics were overrepresented amongst those with Hp-pos_LyG. Subjects with GrG had a high prevalence of erosions and ulcers. Clinical awareness of these conditions was dismal (<1:10,000 patients). Some clinical manifestations were more common in patients with certain gastritides (e.g., vomiting and diarrhea in CollG; anemia in LyG), but none were sufficiently distinctive to suggest a clinical diagnosis. EoG was associated with EoE; LyG had a strong association with celiac disease; CollG with microscopic colitis; and GrG with Crohn disease. CONCLUSIONS The diagnosis of these gastritides (between <1: in 1,000 and 1 in 5000 subjects) rests on histopathology. They remain poorly characterized and clinically neglected. Yet, their associations may herald other conditions: eosinophilic gastrointestinal diseases (EGID), celiac, and Crohn disease. Patients might benefit from increased detection and characterization.
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Affiliation(s)
- Robert M Genta
- Inform Diagnostics, Irving, TX, USA; Departments of Pathology and Medicine (Gastroenterology), Baylor College of Medicine, Houston, TX, USA.
| | - Massimo Rugge
- Department of Pathology, University of Padova, Padova, Italy
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3
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Vronsky D, Finkelstein A, Shiber S, Heching M, Eliakim-Raz N, Ayalon-Dangur I. A Profound Vitamin B12 Deficiency in a Patient with Lofgren's Syndrome. Int Med Case Rep J 2023; 16:655-658. [PMID: 37840969 PMCID: PMC10576453 DOI: 10.2147/imcrj.s404956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 07/11/2023] [Indexed: 10/17/2023] Open
Abstract
Lofgren's syndrome is a unique manifestation of sarcoidosis presenting with erythema nodosum, bilateral hilar lymphadenopathy and migratory polyarthritis. A concurrent vitamin B12 deficiency is not well described and may be related to a rare gastrointestinal manifestation of sarcoid and Lofgren's syndrome. We describe a case of a 57-year-old male presented with migratory polyarthritis, erythemic nodules, edema of his legs and fever. His laboratory tests showed anemia with a profound vitamin B12 deficiency. Imaging demonstrated bilateral hilar adenopathy. Pathology revealed non-necrotizing granulomas consistent with sarcoidosis. The patient was started on prednisone and vitamin B12 supplements with improvement of his complaints and vitamin B12 levels. Sarcoidosis can manifest in many extrapulmonary organs, including the gastrointestinal tract, resulting in nutritional deficiencies, such as vitamin B12 deficiency. Treatment of these nutritional deficiencies includes treatment with steroids, as well as vitamin supplementation. We suggest this case to be a rare manifestation of gastrointestinal involvement in Lofgren syndrome; however, a biopsy from the GI tract was not performed to confirm the diagnosis. An informed consent was obtained from the patient. An institutional approval was not required for the publication of this case.
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Affiliation(s)
- Daniella Vronsky
- Internal Medicine Department, Ward E, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
| | | | - Shachaf Shiber
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Rheumatology, Rabin Medical Center, Petach Tikva, Israel
| | - Moshe Heching
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pulmonology, Rabin Medical Center, Petach Tikva, Israel
| | - Noa Eliakim-Raz
- Internal Medicine Department, Ward E, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Irit Ayalon-Dangur
- Internal Medicine Department, Ward E, Rabin Medical Center, Beilinson Campus, Petach Tikva, Israel
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Kc P, Ayele FK, Karki S, Waleed MS. Whipple's Disease Mimicking Sarcoidosis. Cureus 2023; 15:e41839. [PMID: 37575808 PMCID: PMC10423070 DOI: 10.7759/cureus.41839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 08/15/2023] Open
Abstract
Whipple's disease is a rare systemic disease caused by a Tropheryma whipplei infection. Although older literature reports a low rate of incidence, case reports continue to rise due to increased awareness of the disease. Classic Whipple's disease presents as weight loss, diarrhea, and arthralgia and may involve the heart, central nervous system (CNS), or any other organ system. Some patients with Whipple's disease do not have the classic signs and symptoms of the disease. We present a case of Whipple's disease in a patient with poor appetite, weight loss, and granulomatous inflammation of various organs, including the kidneys and spleen, mimicking sarcoidosis. She had presented three years earlier with acute kidney injury (AKI) and hypercalcemia. The renal biopsy revealed diffuse granulomatous interstitial nephritis. Both AKI and hypercalcemia resolved with prednisone; however, her weight loss and decreased appetite continued. The initial positron emission tomography (PET) scan showed increased fluorodeoxyglucose (FDG) avidity in the spleen and large intestine, and the splenic biopsy revealed non-caseating granulomas. A diagnosis of sarcoidosis was made, and she was started on methotrexate with prednisone. Nevertheless, the weight loss and poor appetite were relentless. A repeat PET scan showed increased FDG avidity in loops of the small and large intestines. A small intestinal biopsy revealed positive periodic acid-Schiff (PAS) and negative acid-fast bacilli (AFB) revealing the diagnosis of Whipple's disease. Whipple's disease should be considered in the differential diagnosis of sarcoidosis, especially in those patients worsening on standard immunosuppression.
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Affiliation(s)
- Pawan Kc
- Rheumatology, Emory University School of Medicine, Atlanta, USA
| | | | - Sabin Karki
- Internal Medicine, Suburban Community Hospital (Lower Bucks Hospital), Bristol, USA
| | - Madeeha S Waleed
- Internal Medicine, Suburban Community Hospital (Lower Bucks Hospital), Bristol, USA
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5
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[Sarcoidosis as prime example of a granulomatous disease]. Z Rheumatol 2022; 81:535-548. [PMID: 35927387 DOI: 10.1007/s00393-022-01245-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 10/16/2022]
Abstract
Sarcoidosis is the most frequent immunologically related granulomatous disease and can serve as a model for understanding diseases within this category. The evidence on the diagnostics and treatment is so far limited. It is therefore all the more important that two new and significant guidelines on diagnosis and treatment of sarcoidosis were published during the last 2 years. Additionally, there were more new publications, which were considered for this review article. In this context, this review article provides a current update and overview of sarcoidosis. Pathophysiologically, there is an increasing understanding of the complex processes and interactions involved in the inflammatory processes and granuloma formation. The probability of a diagnosis of sarcoidosis is determined by compatible histology, the exclusion of differential diagnoses and if possible evidence of a multiorgan manifestation. The clinical course is variable and ranges from an asymptomatic manifestation to severe life-threatening organ failure. The most frequently affected organ are the lungs. Pulmonary fibrosis is the most severe form and is also decisive for mortality. An increasing focus is on the extrapulmonary organ manifestations, in particular, cardiac, hepatosplenic, gastrointestinal, renal, ocular and neurological involvement. Treatment, which consists primarily of immunosuppression, should be initiated in cases of organ-threatening or quality of life-impairing activity of the disease. Additional organ-specific management must also be evaluated. In cases of organ failure transplantation should be considered. Due to the limited evidence especially for the treatment of multiorgan sarcoidosis, when possible, patients with this disease should be included in clinical trials.
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6
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Crohn’s Disease Diagnosed in a Man with Sarcoidosis: Coincidence or Correspondence? Case Rep Gastrointest Med 2022; 2022:5943468. [PMID: 35669381 PMCID: PMC9166977 DOI: 10.1155/2022/5943468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 11/23/2022] Open
Abstract
Crohn's disease and sarcoidosis are characterized by noncaseating granulomas, but rarely do they present in the same patient. Their coexistence presents a diagnostic challenge as they are often classified as clinically separate, despite their similarities. We present a case of a 59-year-old man previously diagnosed with pulmonary sarcoidosis who presented to the emergency room with abdominal pain and diarrhea. Colonoscopy revealed multiple ulcers in the colon, with histology in keeping with newly diagnosed Crohn's colitis. The patient had a good clinical response to initiation of steroid therapy and a tumor necrosis factor (TNF) inhibitor.
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Cantalejo Díaz M, Palomares Cano A, Hörndler Algarate C, Ligorred Padilla LA, Serradilla Martín M. Presentation of pancreatic sarcoidosis as a retroperitoneal infiltrative mass. Cir Esp 2022; 100:106-108. [PMID: 34973917 DOI: 10.1016/j.cireng.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/24/2020] [Indexed: 06/14/2023]
Affiliation(s)
- Miguel Cantalejo Díaz
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, Spain.
| | - Ana Palomares Cano
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | | | - Mario Serradilla Martín
- Instituto de Investigación Sanitaria Aragón, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, Spain
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8
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Bani Fawwaz BA, Farooq A, Al-Dwairy A, Ahmad AI, Mian A, Khan AH. Dysphagia: A Rare Presentation of Sarcoidosis. Cureus 2021; 13:e19397. [PMID: 34925999 PMCID: PMC8656134 DOI: 10.7759/cureus.19397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 11/29/2022] Open
Abstract
Gastrointestinal (GI) sarcoidosis is a rare manifestation of this multi-systemic granulomatous disorder. Esophageal involvement is extremely rare and there have been few case reports about this. Our article reports a case of esophageal sarcoidosis in which dysphagia was the main presenting symptom. The main initial treatment of symptomatic sarcoidosis in general and pulmonary sarcoidosis in specific usually involves corticosteroids, however, there are no specific guidelines for the management of GI sarcoidosis. Surprisingly, or maybe not, in our case, the dysphagia did not improve with steroid therapy which prompted further investigations as well as endoscopic intervention.
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Affiliation(s)
| | - Aimen Farooq
- Internal Medicine, AdventHealth Orlando, Orlando, USA
| | - Ahmad Al-Dwairy
- Internal Medicine, MedStar Washington Hospital Center, Washington, USA
| | - Akram I Ahmad
- Internal Medicine, MedStar Washington Hospital Center, Washington, USA
| | - Arooj Mian
- Internal Medicine, AdventHealth Orlando, Orlando, USA
| | - Abu H Khan
- Gastroenterology and Hepatology, AdventHealth Orlando, Orlando, USA
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9
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El Jammal T, Jamilloux Y, Gerfaud-Valentin M, Richard-Colmant G, Weber E, Bert A, Androdias G, Sève P. Challenging Mimickers in the Diagnosis of Sarcoidosis: A Case Study. Diagnostics (Basel) 2021; 11:diagnostics11071240. [PMID: 34359324 PMCID: PMC8304686 DOI: 10.3390/diagnostics11071240] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 07/05/2021] [Accepted: 07/07/2021] [Indexed: 12/19/2022] Open
Abstract
Sarcoidosis is a systemic granulomatous disease of unknown cause characterized by a wide variety of presentations. Its diagnosis is based on three major criteria: a clinical presentation compatible with sarcoidosis, the presence of non-necrotizing granulomatous inflammation in one or more tissue samples, and the exclusion of alternative causes of granulomatous disease. Many conditions may mimic a sarcoid-like granulomatous reaction. These conditions include infections, neoplasms, immunodeficiencies, and drug-induced diseases. Moreover, patients with sarcoidosis are at risk of developing opportunistic infections or lymphoma. Reliably confirming the diagnosis of sarcoidosis and better identifying new events are major clinical problems in daily practice. To address such issues, we present seven emblematic cases, seen in our department, over a ten-year period along with a literature review about case reports of conditions misdiagnosed as sarcoidosis.
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Affiliation(s)
- Thomas El Jammal
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Yvan Jamilloux
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Mathieu Gerfaud-Valentin
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Gaëlle Richard-Colmant
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Emmanuelle Weber
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Arthur Bert
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
| | - Géraldine Androdias
- Department of Neurology, Service Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Lyon University Hospital, F-69677 Bron, France;
| | - Pascal Sève
- Department of Internal Medicine, Lyon University Hospital, 69004 Lyon, France; (T.E.J.); (Y.J.); (M.G.-V.); (G.R.-C.); (E.W.); (A.B.)
- Research on Healthcare Performance (RESHAPE), INSERM U1290, 69373 Lyon, France
- Correspondence: ; Tel.: +33-426-732-636
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Shah N, Mitra A. Gastrointestinal and Hepatic Sarcoidosis: A Review Article. Clin Liver Dis (Hoboken) 2021; 17:301-307. [PMID: 33968393 PMCID: PMC8087901 DOI: 10.1002/cld.1055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 08/24/2020] [Accepted: 10/11/2020] [Indexed: 02/04/2023] Open
Affiliation(s)
- Neil Shah
- Division of Internal MedicineDepartment of MedicineOregon Health & Science UniversityPortlandOR
| | - Arnab Mitra
- Division of Gastroenterology and HepatologyOregon Health & Science UniversityPortlandOR
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11
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Endoscopic and histologic evaluation of the gastrointestinal tract in patients with sarcoidosis. Eur J Gastroenterol Hepatol 2021; 33:639-644. [PMID: 33079782 DOI: 10.1097/meg.0000000000001943] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Sève P, Pacheco Y, Durupt F, Jamilloux Y, Gerfaud-Valentin M, Isaac S, Boussel L, Calender A, Androdias G, Valeyre D, El Jammal T. Sarcoidosis: A Clinical Overview from Symptoms to Diagnosis. Cells 2021; 10:cells10040766. [PMID: 33807303 PMCID: PMC8066110 DOI: 10.3390/cells10040766] [Citation(s) in RCA: 134] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 12/11/2022] Open
Abstract
Sarcoidosis is a multi-system disease of unknown etiology characterized by the formation of granulomas in various organs. It affects people of all ethnic backgrounds and occurs at any time of life but is more frequent in African Americans and Scandinavians and in adults between 30 and 50 years of age. Sarcoidosis can affect any organ with a frequency varying according to ethnicity, sex and age. Intrathoracic involvement occurs in 90% of patients with symmetrical bilateral hilar adenopathy and/or diffuse lung micronodules, mainly along the lymphatic structures which are the most affected system. Among extrapulmonary manifestations, skin lesions, uveitis, liver or splenic involvement, peripheral and abdominal lymphadenopathy and peripheral arthritis are the most frequent with a prevalence of 25-50%. Finally, cardiac and neurological manifestations which can be the initial manifestation of sarcoidosis, as can be bilateral parotitis, nasosinusal or laryngeal signs, hypercalcemia and renal dysfunction, affect less than 10% of patients. The diagnosis is not standardized but is based on three major criteria: a compatible clinical and/or radiological presentation, the histological evidence of non-necrotizing granulomatous inflammation in one or more tissues and the exclusion of alternative causes of granulomatous disease. Certain clinical features are considered to be highly specific of the disease (e.g., Löfgren's syndrome, lupus pernio, Heerfordt's syndrome) and do not require histological confirmation. New diagnostic guidelines were recently published. Specific clinical criteria have been developed for the diagnosis of cardiac, neurological and ocular sarcoidosis. This article focuses on the clinical presentation and the common differentials that need to be considered when appropriate.
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Affiliation(s)
- Pascal Sève
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, 69007 Lyon, France
- Correspondence:
| | - Yves Pacheco
- Faculty of Medicine, University Claude Bernard Lyon 1, F-69007 Lyon, France;
| | - François Durupt
- Department of Dermatology, Lyon University Hospital, 69004 Lyon, France;
| | - Yvan Jamilloux
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
| | - Mathieu Gerfaud-Valentin
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
| | - Sylvie Isaac
- Department of Pathology, Lyon University Hospital, 69310 Pierre Bénite, France;
| | - Loïc Boussel
- Department of Radiology, Lyon University Hospital, 69004 Lyon, France
| | - Alain Calender
- Department of Genetics, Lyon University Hospital, 69500 Bron, France;
| | - Géraldine Androdias
- Department of Neurology, Service Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Lyon University Hospital, F-69677 Bron, France;
| | - Dominique Valeyre
- Department of Pneumology, Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne et Université Paris 13, Sorbonne Paris Cité, 93008 Bobigny, France;
| | - Thomas El Jammal
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
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Paone G, Steffanina A, De Rose G, Leonardo G, Colombo D, Ricci P, Sabetta F, Vaccaro F, Rosato E, Palange P. A life-threatening small bowel obstruction as onset of an unknown sarcoidosis: A case report. Respir Med Case Rep 2021; 33:101379. [PMID: 33786300 PMCID: PMC7994781 DOI: 10.1016/j.rmcr.2021.101379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 02/25/2021] [Accepted: 03/03/2021] [Indexed: 12/17/2022] Open
Abstract
Sarcoidosis is a systemic granulomatous disorder of unknown etiology characterized by non-caseating granulomas at the site of disease. A confident diagnosis should be established by the evidence of typical granulomas on biopsy and after exclusion of other conditions. Clinically recognizable Gastrointestinal involvement (GI) occurs in less than 1.6% of patients with sarcoidosis, with data revealing small intestine participation in 0.03% of the cases and few anecdotal reports describe a peritoneal presentation. Clinical manifestations of peritoneal sarcoidosis are abdominal discomfort, bloating, weight loss, epigastric and peri-umbilical pain with or without ascites, bowel obstruction. Treatment depends on symptoms and disease activity. Herein we describe the case of a 42-years-old male patient who developed an acute, life–threatening small bowel obstruction as first manifestation of sarcoidosis. To the best of our knowledge, this is the only report showing such extensive and acute onset of intra-abdominal sarcoidosis in the absence of a previous disease manifestation and without pulmonary involvement. Abdominal sarcoidosis is a sporadic event and localization without pulmonary involvement is rarer mimicking GI diseases. Reaching abdominal sarcoidosis diagnosis is not a straightforward process. It is pivotal to confirm sarcoidosis diagnosis before subjecting patients to an appropriate treatment. Corticosteroids are considered the cornerstone treatment. Asymptomatic patients may undergo a watch and wait follow-up with no need for a pharmacological therapy. Surgery is not often required but individualized patient evaluation is recommended.
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Affiliation(s)
- Gregorino Paone
- Department of Cardiovascular, Respiratory, Nephrologic, Anesthesiologic, Geriatric Sciences La Sapienza University of Rome, Rome, Italy.,Department of Public Health and Infectious Diseases, La Sapienza University of Rome, Rome, Italy
| | | | - Giulia De Rose
- Department of Public Health and Infectious Diseases, La Sapienza University of Rome, Rome, Italy
| | | | - Daniele Colombo
- Department of Biomedicine and Prevention, Anatomic Pathology Section, University of Rome Tor Vergata, Rome, Italy
| | - Paolo Ricci
- Department of Radiology, Oncology and Pathology, Sapienza University of Rome, Rome, Italy
| | | | - Francesco Vaccaro
- Department of Public Health and Infectious Diseases, La Sapienza University of Rome, Rome, Italy
| | - Edoardo Rosato
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Paolo Palange
- Department of Public Health and Infectious Diseases, La Sapienza University of Rome, Rome, Italy
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El-Zimaity H, Riddell RH. Beyond Helicobacter: dealing with other variants of gastritis-an algorithmic approach. Histopathology 2020; 78:48-69. [PMID: 33382486 DOI: 10.1111/his.14283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/11/2020] [Accepted: 10/20/2020] [Indexed: 12/15/2022]
Abstract
In daily practice, the presence of inflammation in gastric biopsies prompts a mental algorithm, an early question being whether the lesion present is Helicobacter-associated. If Helicobacter organisms are not found, then there is a further algorithm, governed by the predominant type of inflammatory cells present, and the presence of other features such as intraepithelial lymphocytosis, a subepithelial collagen band, granulomas, coexisting chronic inflammation, focality, and superimposed reactive changes including erosions and ulcers. Each of these generates its own differential diagnosis. If no inflammation is present, then the two major changes specifically looked for are the changes associated with hypergastrinaemia, by far the most common cause of which is treatment with proton pump inhibitors, and reactive changes. These may be present with and without accompanying inflammation, and, when the epithelial changes dominate, the term gastropathy is preferred. In this article, we present an approach to non-Helicobacter inflammation and gastropathies.
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Cantalejo Díaz M, Palomares Cano A, Hörndler Algarate C, Ligorred Padilla LA, Serradilla Martín M. Presentation of pancreatic sarcoidosis as a retroperitoneal infiltrative mass. Cir Esp 2020; 100:S0009-739X(20)30359-6. [PMID: 33276966 DOI: 10.1016/j.ciresp.2020.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/21/2020] [Accepted: 10/24/2020] [Indexed: 11/21/2022]
Affiliation(s)
- Miguel Cantalejo Díaz
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España.
| | - Ana Palomares Cano
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España
| | | | | | - Mario Serradilla Martín
- Instituto de Investigación Sanitaria Aragón, Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario Miguel Servet, Zaragoza, España
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Tang G, Benavides DR. Clinical Reasoning: A patient with a history of weight loss presenting with seizures. Neurology 2020; 95:e2038-e2042. [PMID: 32651288 DOI: 10.1212/wnl.0000000000010344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Garland Tang
- From the Department of Neurology, University of Maryland School of Medicine, Baltimore
| | - David R Benavides
- From the Department of Neurology, University of Maryland School of Medicine, Baltimore.
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Egal A, London J, Lidove O, Atienza P, Etienney I. [Anorectal manifestations in systemic diseases]. Rev Med Interne 2019; 40:729-732. [PMID: 31400822 DOI: 10.1016/j.revmed.2019.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/08/2019] [Accepted: 07/17/2019] [Indexed: 11/25/2022]
Abstract
Numerous systemic diseases (vasculitis, connective tissue disease or sarcoidosis) can display an involvement of the perianal skin, the rectum and/or the anus. Such knowledge is important in order to treat these complications specifically when possible. Lesions of the anorectum arising from systemic diseases can sometimes cause perforations in the peritoneal cavity (if concerning the higher portion of the rectum) and/or fistulization to the anal margin. Differential diagnosis, mostly infectious or inflammatory (Crohn's disease) must be ruled out in every case. Other systemic diseases can display specific manifestations as this is the case in scleroderma which can lead to anal incontinence. Despite the relative rarity of these manifestations, their ignorance would forbid global management of these complex diseases. It should thus be detected in each consultation and a regular follow-up must be provided with a proctologist and/or a gastroenterologist when needed.
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Affiliation(s)
- A Egal
- Service de proctologie chirurgicale, hôpital Croix Saint-Simon, 75020 Paris, France.
| | - J London
- Service de médecine interne, hôpital Croix Saint-Simon, 75020 Paris, France
| | - O Lidove
- Service de médecine interne, hôpital Croix Saint-Simon, 75020 Paris, France
| | - P Atienza
- Service de proctologie chirurgicale, hôpital Croix Saint-Simon, 75020 Paris, France
| | - I Etienney
- Service de proctologie chirurgicale, hôpital Croix Saint-Simon, 75020 Paris, France
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Abstract
Involvement of the gastrointestinal (GI) tract is an infrequent extrathoracic presentation of sarcoidosis. We reviewed 305 cases of GI involvement reported in 238 patients, in whom GI sarcoidosis was the first sign of the disease in half the cases. The disease does not affect the GI tract uniformly, with a clear oral-anal gradient (80% of reported cases involved the esophagus, stomach, and duodenum). Clinicopathological mechanisms of damage may include diffuse mucosal infiltration, endoluminal exophytic lesions, involvement of the myenteric plexus, and extrinsic compressions. Ten percent of patients presented with asymptomatic or subclinical disease found on endoscopy. The diagnosis is relevant clinically because 22% of cases reviewed presented as life threatening. In addition, initial clinical/endoscopic findings may be highly suggestive of GI cancer. The therapeutic approach is heterogeneous and included wait-and-see or symptomatic approaches, glucocorticoid/immunosuppressive therapy, and surgery. Sarcoidosis of the gut is a heterogeneous, potentially life-threatening condition that requires a multidisciplinary approach and early clinical suspicion to institute personalized therapeutic management and follow-up.
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Yorita K, Iwamura S. Can colonic inflammatory polyp with numerous immunoglobulin G4-positive plasma cells represent a colonic manifestation of immunoglobulin G4-related disease? A case report. Clin J Gastroenterol 2019; 12:398-402. [PMID: 30895472 DOI: 10.1007/s12328-019-00966-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 03/11/2019] [Indexed: 01/13/2023]
Abstract
We present an asymptomatic case of a 79-year-old Japanese man who had a 6 mm colonic inflammatory polyp with numerous immunoglobulin G4 (IgG4)-positive plasma cells. No symptoms or abnormal laboratory data, such as changes in serum IgG4 levels, were found at the time of diagnosis or during the 1 year of follow-up thereafter. Additionally, no diffuse/localized swelling or masses were found in organs, except for colonic polyps, by abdominal computed tomography 1 year prior to the polypectomy. Inflammatory myofibroblastic tumor was unlikely from the lack of spindle cell proliferation and ALK immunoreactivity. This is the first case of this colonic polyp in an asymptomatic person. This polyp could be probable for single organ manifestation of IgG4-related disease (IgG4-RD), according to the comprehensive diagnostic criteria for IgG4-RD published in 2012; however, colonic manifestation of IgG4-RD has not been clarified owing to its rarity, and colon-specific criteria for IgG4-RD have not been proposed. Thus, we could not definitively establish the colonic polyp as IgG4-RD. Therefore, careful clinicopathological evaluation is needed to reveal whether this colonic polyp represents a nonspecific inflammatory response or an early manifestation of IgG4-RD.
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Affiliation(s)
- Kenji Yorita
- Department of Diagnostic Pathology, Japanese Red Cross Kochi Hospital, 2-13-51 Shinhonmachi, Kochi-shi, Kochi-ken, 780-8562, Japan.
| | - Shinichi Iwamura
- Department of Gastroenterology, Japanese Red Cross Kochi Hospital, 2-13-51 Shinhonmachi, Kochi-shi, Kochi-ken, 780-8562, Japan
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Mehta V, Desai D, Abraham P, Rodrigues C. Making a Positive Diagnosis of Intestinal Tuberculosis with the Aid of New Biologic and Histologic Features: How Far Have We Reached? Inflamm Intest Dis 2019; 3:155-160. [PMID: 31111030 DOI: 10.1159/000496482] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 12/31/2018] [Indexed: 12/21/2022] Open
Abstract
Background The diagnosis of intestinal tuberculosis (TB) and its differentiation from Crohn's disease (CD) remain a challenge. We review here in detail the various methods for the diagnosis of intestinal TB. Summary Colonoscopy findings in intestinal TB are useful and suggestive; histopathology of colonoscopic biopsies is contributory but rarely confirmatory. Increasing the number of colonoscopic biopsies increases the histological yield. Recent culture methods that have improved the yield for TB offer hope. Mycobacteria Growth Indicator Tube (MGIT) culture is now the standard of care as its yield is superior to that of the traditional Lowenstein-Jensen medium. Increasing the number of colonoscopic biopsy samples for MGIT culture can increase the yield. The culture and histology are complimentary. Even then a significant proportion of patients do not have a positive diagnosis of intestinal TB. Scoring systems have been developed with a sensitivity and specificity of 90 and 60%, respectively, but their utility in routine practice is yet to be established. Similarly, the ratio of visceral fat to total fat is helpful in differentiating CD from intestinal TB. Polymerase chain reaction has been used but its value seems uncertain. Gene Xpert® in an emerging technique that has been found to be useful in the diagnosis of pulmonary TB, and its utility in intestinal TB needs to be looked at. Newer technologies like TB-LAMP (loop-mediated isothermal amplification) need to be assessed in clinical studies. Key Message Optimization of the present diagnostic tools (taking an adequate number of biopsies for histology and culture) and study of newer techniques to learn their actual utility seems to be the way forward.
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Affiliation(s)
- Vatsal Mehta
- Divisions of Medical Gastroenterology and Microbiology, P.D. Hinduja Hospital, Mumbai, India
| | - Devendra Desai
- Divisions of Medical Gastroenterology and Microbiology, P.D. Hinduja Hospital, Mumbai, India
| | - Philip Abraham
- Divisions of Medical Gastroenterology and Microbiology, P.D. Hinduja Hospital, Mumbai, India
| | - Camilla Rodrigues
- Divisions of Medical Gastroenterology and Microbiology, P.D. Hinduja Hospital, Mumbai, India
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Brown I, Kumarasinghe MP. Granulomas in the gastrointestinal tract: deciphering the Pandora's box. Virchows Arch 2017; 472:3-14. [PMID: 28776106 DOI: 10.1007/s00428-017-2210-3] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 07/17/2017] [Accepted: 07/20/2017] [Indexed: 12/18/2022]
Abstract
Granulomas are organised collection of activated histiocytes induced by a persistent antigen stimulus. A wide variety of antigens encountered by the gastrointestinal tract are of this nature and hence the resulting granulomatous inflammation represents a tissue reaction pattern. The potential causes can be broadly classified as infections or non-infectious immune reactions. There is also a group where a cause is never identified. Granulomas may be of varying morphological appearance, most commonly epithelioid, foreign body type, suppurative and necrotizing. This may provide a clue as to the aetiology; however, in most cases, the cause requires further inquiry. Pathologists may need to cut deeper levels to look for foreign material and apply special stains to look for microorganisms. Pathologists also need to be certain that the process is a true granuloma and not a mimic. The site of occurrence in the gastrointestinal tract and the clinical setting is often paramount in establishing the aetiology. For instance, infections are more likely the cause in developing countries or when there is immunosuppression. Similarly, granulomas in the stomach are usually due to Crohn's disease; however, it is only rarely the cause of granulomas isolated to the appendix.
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Affiliation(s)
- Ian Brown
- Envoi Pathology, 5/38 Bishop Street, Kelvin Grove, Brisbane, QLD, 4059, Australia. .,Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Marian Priyanthi Kumarasinghe
- School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Australia.,PathWest Laboratory Medicine, Queen Elizabeth II Medical Centre, Nedlands, Australia
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