Hepatic Sarcoidosis

Cirrhosis due to hepatic sarcoidosis: A rare presentation

Key Clinical Message

Sarcoidosis, although predominantly affecting the lungs, can present with cirrhosis, posing diagnostic challenges. Elevated ACE levels and atypical liver enzyme patterns should prompt consideration of sarcoidosis in cryptogenic cirrhosis cases, necessitating comprehensive evaluation including liver biopsy and imaging for accurate diagnosis and timely management.

Abstract

Sarcoidosis is a systemic disease that can affect various organs, leading to a diverse range of clinical manifestations that make diagnosis challenging. Here, we present a case of sarcoidosis in a middle-aged male who presented with cirrhosis. The cause of cirrhosis remained unknown for 4 years until the development of lymphadenopathy and ground-glass opacities on lung imaging. A liver biopsy was performed, which revealed noncaseating granulomatous inflammation, thereby identifying sarcoidosis as the cause of cirrhosis. The patient was treated with oral steroids, which slightly improved his liver function over a short period. Given the diverse presentations of sarcoidosis, it should be considered as a possible differential diagnosis in cases of cryptogenic cirrhosis.

Improvement of liver histology in hepatic sarcoidosis due to treatment with corticosteroids and ursodeoxycholic acid: a case report

We report the case of a 48-year-old male with a history of pulmonary and ocular sarcoidosis. Non-caseating granulomas, identified histologically, are the most characteristic manifestation of sarcoidosis. Hepatic sarcoidosis is difficult to diagnose using radiological imaging. In the patient reported in this study, ultrasound and contrast-enhanced computed tomography scans identified multiple intra-abdominal lymphadenopathies, with evidence of liver and splenic infiltrations. The first liver biopsy revealed non-caseating granulomatous hepatitis consistent with hepatic sarcoidosis. The patient was treated with ursodeoxycholic acid (UDCA), but his laboratory parameters did not improve. Prednisone was initiated at a dose of 30 mg daily and slowly tapered. At a dose of 12.5 mg daily, marked improvements in the fibrotic and sarcoid-like lesions were noted at the second biopsy. A third biopsy was performed, with the patient on a prednisone taper of 5 mg/day showed mild fibrous expansion in the portal tracts and mild parenchymal necro-inflammatory lesions. However, overall, fibrosis marker levels remained stable over the course of treatment. A fourth biopsy was performed after a 5-year course of 5 mg/day prednisone. This revealed minimal lobular inflammation without fibrosis. Thus, treatment of this patient with corticosteroids and UDCA resulted in marked improvements in his biochemical and histological parameters.

Characteristics and clinical outcomes of patients with sarcoidosis admitted for ST-elevation myocardial infarction in the United States: a propensity matched analysis from the National Inpatient Sample

Introduction

Sarcoidosis is a systemic inflammatory disorder characterised by non-caseating granulomas. Cardiac sarcoidosis (CS) normally causes conduction abnormalities, ventricular arrhythmias, and heart failure. Little is known about the characteristics and impact of sarcoidosis in patients admitted with ST-elevation myocardial infarction (STEMI). This study aims to fill this void.

Material and methods

Utilising the National Inpatient Sample (NIS) database (2016-2020), individuals with STEMI were identified and categorised based on sarcoidosis presence whilst adjusting for confounders via logistic regression models.

Results

Among 851,290 STEMI patients, 1215 had sarcoidosis. Before propensity matching, sarcoidosis patients were notably different in demographics and comorbidities compared to non-sarcoidosis patients. After propensity score matching (PSM), sarcoidosis patients were found to have a higher incidence of supraventricular tachycardia (SVT) (2.5% vs. 1.3%, p = 0.024) and acute kidney injury (AKI) (23.3% vs. 20.8%, aOR = 1.269, 95% CI: 1.02-1.58, p = 0.033) but a lower incidence of undergoing coronary artery bypass graft (CABG) (5.5% vs. 8.5%, aOR = 0.663; 95% CI: 0.472-0.931, p = 0.018), while no significant disparities were noted in PCI, cardiogenic shock, mortality, or mean length of stay (LOS).

Conclusions

Using propensity-matched large real-world data of STEMI patients, sarcoidosis was associated with fewer cases of CABG and a greater incidence of AKI and SVT compared to non-sarcoidosis patients.

Hepatic Sarcoidosis Found Incidentally in a Patient Presenting With Recurrent Clostridium difficile Infections

A 50-year-old female who presented to our hospital for recurrent diarrhea was found to have worsening aminotransferase and alkaline phosphatase levels. Workup revealed lymphadenopathy and hepatomegaly prompting a biopsy of the liver and axillary lymph node, confirming a diagnosis of hepatic sarcoidosis. Our patient later developed cutaneous sarcoidosis. She is currently asymptomatic and is followed by gastroenterology, pulmonary, and dermatology. Recognition of extrapulmonary manifestations of sarcoidosis is important for proper management of patients. Treatment often requires a multidisciplinary approach when more than one organ system is involved.

Cutaneous Sarcoidosis: A Differential Diagnosis to Consider in Undiagnosed Skin Lesions

The presentation of sarcoidosis varies depending on the organs involved. Cutaneous sarcoidosis usually presents with other organ involvement, but isolated presentation is possible. However, diagnosing isolated cutaneous sarcoidosis can be challenging in resource-poor countries, particularly where sarcoidosis is relatively uncommon, since cutaneous sarcoidosis usually does not cause troublesome symptoms. We present a case of cutaneous sarcoidosis in an elderly female who had been suffering from skin lesions for nine years. The diagnosis was made after the appearance of lung involvement, which raised the suspicion of sarcoidosis and prompted a skin biopsy. The patient was then treated with systemic steroids and methotrexate, and her lesions improved shortly thereafter. This case highlights the importance of considering sarcoidosis as a possible cause of undiagnosed, refractory cutaneous lesions.

Secondary sclerosing cholangitis: mimics of primary sclerosing cholangitis

Sclerosing cholangitis is a chronic cholestatic disease characterized by stricturing, beading, and obliterative fibrosis of the bile ducts. Sclerosing cholangitis is considered primary (PSC) if no underlying etiology is identified or secondary (SSC) if related to another identifiable cause. In this article, we will review the clinical features, pathogenesis, diagnosis, and imaging findings of PSC and SSC, with an emphasis on features that may aid in the distinction of these entities. We will also discuss various etiologies of SSC including recurrent pyogenic cholangitis, other infectious etiologies, ischemic damage, toxic insults, and immunologic, congenital, and miscellaneous causes, highlighting the unique imaging findings and clinical context of each diagnosis.

Sarcoidosis in Johannesburg, South Africa: A retrospective study

Background

Sarcoidosis is a multisystem granulomatous condition of uncertain aetiology that most frequently affects the lungs. Because of clinical and radiological similarities with tuberculosis (TB), particularly in high-prevalence regions, sarcoidosis is frequently misdiagnosed as TB.

Objectives

To review the clinical features of sarcoidosis patients in a South African (SA) population, adding clinical information to the relatively few studies that have been conducted in SA patients with sarcoidosis.

Methods

This was a retrospective study of 102 sarcoidosis patients conducted between 2002 and 2006 at the Charlotte Maxeke Johannesburg Academic Hospital.

Results

Of 102 sarcoidosis patients, there were 69 (67.6%) females and 33 (32.4%) males. The majority (85.3%) were non-smokers. The mean age of the group was 44.6 years. One-third of patients had chronic comorbid diseases. Almost 17% had been treated initially for TB, prior to being diagnosed as having sarcoidosis. Two patients developed active TB while receiving corticosteroid treatment for sarcoidosis. The salient clinical manifestations were dry cough (the most common presenting symptom in 82.4%), dyspnoea in 53.9%, cutaneous lesions other than erythema nodosum in 33.3%, and on lung examination crackles were noted in 37.3% of patients. Raised angiotensin-converting enzyme (ACE) levels were found in 56.8% of patients. The majority (48%) of patients had stage II chest radiographic changes. Cutaneous (28.4%), mediastinal lymph node (25.5%) and transbronchial lung (25.5%) biopsies were the most frequent sites confirming granulomatous inflammation. Overall, 21.2% of patients had obstructive airway disease. Systemic corticosteroids were indicated in 87.3% of patients and the relapse rate was 60.7%.

Conclusion

Sarcoidosis is often initially misdiagnosed as TB in SA. The most common biopsy sites for histological confirmation were the skin and mediastinal lymph nodes, and transbronchial lung biopsies were also frequently taken. Stage II chest radiographic changes were most common. Overall, systemic corticosteroids were administered in 87.3% of cases and the relapse rate was 60.7%.

A case of hepatic and bone marrow sarcoidosis with progressive renal failure: diagnostic and therapeutic challenges

Sarcoidosis is a systemic granulomatous disease, sometimes characterized by an extrapulmonary localization in 30 - 50% of cases. We describe a 60-year-old Italian man with an unexplained history of fatigue, ascitis and progressive renal function impairment. Diagnosis of hepatic and bone marrow sarcoidosis was established by histology, and fast improvement of renal function was obtained after starting  corticosteroid therapy. Atypical presentation and simultaneous involvement of liver, bone marrow and kidneys make diagnosis of extrapulmonary sarcoidosis still a diagnostic challenge. Delayed diagnosis could lead to serious organ damage like a progressive severe kidney failure.

Elderly Onset Sarcoidosis: A Case Report

Sarcoidosis is a multi-organ autoimmune disease that affects females more than males. While primarily considered as a disease of the young, very few cases of sarcoidosis have been reported in patients over 65 years old. We report the case of sarcoidosis in an 80-year-old female and ultimately died from sarcoidosis-related complications. We review the literature and highlight key differences in elderly onset sarcoidosis when compared to the general population. We also advise physicians to have a high index of suspicion for sarcoidosis in the elderly who present with hypercalcemia and abnormal findings on chest imaging.

Hepatic sarcoidosis: Clinical characteristics and outcome

BACKGROUND & AIMS

Clinical manifestation of hepatic involvement in sarcoidosis can vary from asymptomatic disease to severe complications such as cirrhosis and portal hypertension. However, data on hepatic sarcoidosis are limited, and evidence-based recommendations are lacking. Our study aimed to assess the features and clinical course of hepatic sarcoidosis in a predominantly Caucasian cohort.

METHODS

We performed a retrospective study including all patients with hepatic sarcoidosis between 2004 and 2020 in 5 German centres. The median follow-up time was 36 months (range 0.0-195). Data on demographic parameters, clinical manifestations, diagnostic test results, treatment, and outcome were collected.

RESULTS

A total of 1,476 patients with sarcoidosis and 62 patients with hepatic involvement (4.2%) were identified. Of the patients, 51.6% were female, and 80.6% were Caucasian. Most patients were asymptomatic and were observed to have a cholestatic pattern of liver enzyme elevations. Cirrhosis was detected in 9 patients (14.5%), of whom 6 developed clinical manifestations of portal hypertension. Fifty-four patients were medically treated, most commonly with glucocorticoids (69.4%) or ursodeoxycholic acid (UDCA) (40.3%). Levels of alkaline phosphatase (ALP) decreased by 60.8% on average from baseline in patients treated with glucocorticoids and by 59.9% in patients treated with UDCA. Seventeen patients received treatment augmentation with a second line agent, of whom 8 patients normalised ALP levels during follow-up. None of the patients underwent liver transplantation or developed hepatocellular carcinoma (HCC). Three of the patients died during follow-up owing to liver-related complications.

CONCLUSIONS

Hepatic involvement in sarcoidosis was found in 4.2% of patients with sarcoidosis and was clinically significant in 14.5% of those. These findings highlight the importance of early identifying, monitoring, and treating hepatic sarcoidosis, given its increased mortality when associated with end-stage liver disease.

LAY SUMMARY

Clinical diagnostic and surveillance of hepatic involvement in sarcoidosis has not been standardised, and management of hepatic involvement is a clinical challenge, since it remains poorly characterised in many ways. Our results show that one-third of patients with hepatic sarcoidosis presented with clinically significant portal hypertension, 14.5% suffered from cirrhosis, and 3 patients died owing to liver-related complications. Regarding pharmacological treatment options, corticosteroids and UDCA were the medical agents most frequently used, and both of them have been shown to induce biochemical response in the majority of patients. These findings highlight the importance of correctly and early identifying hepatic involvement in sarcoidosis, because of the potentially progressive course of disease.

Imaging of Biliary Involvement in Sarcoidosis: Computed Tomography, Magnetic Resonance Cholangiopancreatography, and Gadolinium Ethoxybenzyl Diethylenetriamine Pentaacetic Acid-Enhanced Magnetic Resonance Imaging Findings

Sarcoidosis is a multisystem disease usually affecting the chest, hilar lymph nodes, and lungs, but can potentially involve any organ; therefore, its clinical presentation may vary. Hepatobiliary involvement is rare, and typically asymptomatic; however, it can lead to cirrhosis, and may require liver transplantation. In this report, we present a rare case of a patient affected by sarcoidosis with hepatobiliary involvement. He presented to our hospital complaining of dyspnea triggered by moderate efforts and oppressive thoracic discomfort. Chest X-ray showed multiple bilateral nodular opacities and enlargement of both hilar regions, confirmed by a subsequent total-body computed tomography scan and positron emission tomography, which also revealed cardiac, splenic, and hepatic involvement. Liver function was studied via gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging, and magnetic resonance cholangiopancreatography (MRCP) was also performed. The diagnosis of sarcoidosis was finally achieved via liver biopsy, revealing non-necrotizing granulomas in the periportal space. The patient was treated with prednisone per os, with regression of all lesions at all levels. Although other cases of biliary sarcoidosis have been described, this report provides a complete image set of Gd-EOB-DTPA-enhanced magnetic resonance and MRCP images that is lacking in the English literature, and which may be useful for diagnosis.

Sarcoidosis Manifesting as Liver Granuloma With Asteroid Bodies

Sarcoidosis is an autoimmune disease, which most commonly affects the lungs and lymph nodes and is characterized with non-caseating granulomas. Hepatic involvement in sarcoidosis occurs in less than 1% of patients. Most patients with hepatic sarcoidosis remain asymptomatic with only laboratory abnormalities. We present the case of a 59-year-old man with sarcoidosis who was evaluated for an elevation of alkaline phosphatase. Laboratory test results revealed an alkaline phosphatase level of 230 U/L, with normal alanine aminotransferase, aspartate aminotransferase, bilirubin, and albumin. Computed tomography of the abdomen and pelvis with intravenous contrast of the liver showed a mildly enlarged liver. Liver biopsy sections showed steatosis, active steatohepatitis, and focal portal granuloma formation with asteroid body. The patient was scheduled regular liver function tests and clinical monitoring. Most patients with hepatic sarcoidosis remain asymptomatic with only laboratory abnormalities such as elevation of liver enzymes and alkaline phosphatase. Although liver involvement is common in gastrointestinal sarcoidosis, progression to liver cirrhosis is rare in such patients. While symptomatic patients may be managed with systematic prednisone, asymptomatic patients may require only laboratory and clinical monitoring.

Sarcoidosis Masquerading as Long-Standing Cholestasis

Hepatic sarcoidosis is an exceedingly rare extrapulmonary manifestation of sarcoidosis, with the majority remaining stable for years without clinical clues, only displaying biochemical abnormalities. Amongst the literature, the timeline to cirrhosis has not been parsed out; hepatomegaly develops in 50% and cirrhosis in 33% of all hepatic sarcoidosis patients, making this an essential issue in this patient population. Interestingly, the risk for hepatocellular carcinoma remains high regardless of cirrhosis development. Corticosteroids and biologics remain the mainstay of therapy, although refractory cases may require deeper immunosuppression. Liver transplantation is seen in a handful of cases with promising results. We present an interesting case of cholestatic pattern livery injury in our outpatient setting that was eventually discovered to be hepatic sarcoidosis. Mild biochemical derangements or sole elevations in alkaline phosphatase are under-recognized, and patients often progress to cirrhosis and end-stage liver disease. This diagnostic miss has significant implications and represents an opportunity to treat liver disease with a reversible cause. Consensus guidelines recommend alkaline phosphatase screening in newly diagnosed cases of sarcoidosis.

Sarcoidosis: A Clinical Overview from Symptoms to Diagnosis

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.

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.

Atypical Sarcoidosis Diagnosed by Massive Splenomegaly

We examined a 22-year-old woman who was admitted to our hospital with abdominal distention. At 19 years of age, the patient presented with hepatosplenomegaly. She was examined several times in another hospital; however, the cause was unidentified. Our evaluation showed severe pancytopenia and a spleen 13×24 cm in size. The serum levels of angiotensin-converting enzyme and lysozyme were elevated. She was diagnosed with liver sarcoidosis based on non-caseating epithelioid granuloma in liver biopsy tissue. To improve the symptoms, splenectomy was performed, and her pancytopenia and symptoms improved. Sarcoidosis should be considered in cases of massive splenomegaly.

Budd-Chiari Syndrome in a Patient With Simultaneous Diagnosis of Hepatic Sarcoidosis and Nodular Regenerative Hyperplasia

Budd-Chiari syndrome (BCS) is a rare vascular disorder characterized by an obstruction of the hepatic venous outflow. Nodular regenerative hyperplasia (NRH) may develop as a result of an underlying autoimmune disease such as hepatic sarcoidosis. Only a few case reports have described cases with either NRH or hepatic sarcoidosis associated with BCS. We present a 42-year-old man presenting with BCS and signs of portal hypertension who was found to have an underlying pathological diagnosis of both hepatic sarcoidosis and NRH and who was successfully treated with a transjugular intrahepatic portosystemic shunt.

Hepatic Sarcoidosis Complicated with Pancreatic Adenocarcinoma

Sarcoidosis is a systemic noncaseous granulomatous disease. The liver is a common location but usually asymptomatic. Current literature suggests an association between sarcoidosis and cancers. However, there is a lack of definite evidence. We present a case of a 59-year-old man with jaundice and acutely elevated alkaline phosphatase. The diagnosis was confirmed by obtaining a liver biopsy and was treated with 6 months of steroids. A year later, he had a recurrence of jaundice. MRCP showed biliary dilatation and a mass in the pancreatic head, confirmed by biopsy to be adenocarcinoma. This is the first case to be reported of hepatic sarcoidosis associated with pancreatic cancer.

Hepatic Sarcoidosis: Natural History and Management Implications

Introduction: Hepatic granulomas are common in patients with sarcoidosis, but clinically significant liver disease is uncommon and poorly studied. We aimed to characterize the frequency and clinical course of hepatic sarcoidosis in an ethnically diverse population.

Methods: This is a retrospective study including all cases of hepatic sarcoidosis in a single center. The median follow-up time was 49 months (4–121). Cases were identified based on ICD-9 and ICD-10 codes for granulomatous hepatitis, sarcoidosis, and hepatic sarcoidosis. The Chi-square and Wilcoxon-signed rank tests were used as indicated to assess for differences between groups.

Results: Of 286 patients with sarcoidosis, 27 had hepatic involvement; 78% were female and 48% African American. The most common pattern of liver tests abnormalities was cholestatic. Ten patients had clinically significant hepatic involvement: cirrhosis in seven (25.9%), portal hypertension in nine (33%), and portal vein thrombosis in one (3.7%). Sex, race, and ethnicity were not associated with an increased risk of hepatic involvement or symptomatic hepatic sarcoidosis. Most patients received medical treatment, most commonly oral glucocorticoids. At the end of the follow-up period, all patients were alive but two had undergone liver transplantation due to complications of hepatic sarcoidosis. Three patients with hepatic sarcoidosis had initially been classified as AMA-negative PBC.

Conclusions: Hepatic sarcoidosis was found in 9.4% of patients with sarcoidosis and was clinically significant in 37% of those. Identifying and monitoring hepatic sarcoidosis is crucial given its potential complications.

Sustained effectiveness, safety and therapeutic drug monitoring of tioguanine in a cohort of 274 IBD patients intolerant for conventional therapies

BACKGROUND

Tioguanine (or thioguanine) is an alternative drug for IBD patients who fail prior conventional immunomodulating therapy.

AIM

To report effectiveness, safety and therapeutic drug monitoring in a cohort of patients with prolonged tioguanine maintenance therapy.

METHODS

In this nationwide, multicentre study, medical records of tioguanine- using IBD patients were retrospectively reviewed. Response to therapy was defined as clinical effectiveness without (re)initiation of corticosteroids, concurrent biological therapy or surgical intervention. All adverse events that occurred during the follow-up were listed and graded according to the common terminology criteria (CTC).

RESULTS

Two hundred and seventy-four patients (female 63%, Crohn's disease in 68%) were included with median treatment duration of 51 months, 1567 patient-years of follow-up and median 20 mg/d tioguanine dosage. Tioguanine was tolerated in 79%, clinical effectiveness at 6 months was documented in 66% and sustained clinical effectiveness during 12 months in 51% of patients. Forty-one per cent of patients developed adverse events: 5% were graded as severe. Adverse events comprised infection requiring hospitalisation in three and skin cancer in eight patients (two melanomas). Asymptomatic nodular regenerative hyperplasia of the liver occurred in two out of 52 patients with liver biopsies (3.8%) and portal hypertension in three whereof one potentially associated with tioguanine (0.4%). Clinical effectiveness was correlated with 6-thioguanine nucleotide threshold concentrations >682 pmol/8×10⁸ RBC (P < 0.05).

CONCLUSIONS

Long-term tioguanine therapy for at least 12 months was effective in 51% and well tolerated as a maintenance treatment for IBD in about 70% of patients. Adverse events were common, but mainly mild or moderate. 6-Thioguanine nucleotide threshold concentration ≥ 700 pmol/8×10⁸ RBC is proposed as target level with higher odds for clinical effectiveness.

Hepatic involvement in sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Liver is frequently involved in the pathological process. Wide range of clinical manifestations can be seen: from asymptomatic lesion with normal liver function tests to cirrhosis with portal hypertension. Biopsy plays the key role in diagnosis of the hepatic sarcoidosis. It is essential for morphological diagnosis to exclude other causes of granulomatous liver disease, most often - primary biliary cholangitis. Nowadays there are no standard treatment protocols for patients with hepatic sarcoidosis.

Hepatic Involvement in Systemic Sarcoidosis

Patient: Female, 68

Final Diagnosis: Hepatic sarcoidosis

Symptoms: Abdominal pain • nausea • weakness

Medication: —

Clinical Procedure: Liver biopsy

Specialty: Gastroenterology and Hepatology

Common symptoms for a rare disease in a girl with sarcoidosis: a case report

Background

Sarcoidosis in pediatric age is uncommon and challenging diagnosis, because manifestations can be significantly variable and non-specific since it is a multisystem disease, and virtually any organ system may be involved.

Case presentation

In this report, we describe the case of a 12-year-old girl presenting with fatigue and weight loss, with a painless hepato-splenomegaly without additional clinical signs on physical examination. In our patient, once we had ruled out infections, malignancies and granulomatous diseases of childhood, we made diagnosis of sarcoidosis, finding suggestive histological features in two different tissues (liver and lymph nodes) with lung involvement.

Conclusions

Our case points out that pediatricians should consider sarcoidosis in the differential diagnosis in case of systemic symptoms, even in absence of other specific clinical clues, because they represent the most common clinical manifestations on presentation in children, in order to refer promptly the young patient to specialist evaluation.

Hepatic Sarcodosis presenting as portal hypertension in a young boy

A 13-year-old boy, known case renal stone disease came with the complaints of abdominal pain along with low grade fever. On examination, hepatosplenomegaly was noted while his lab reports showed a low hemoglobulin with a raised ESR. His blood and urine cultures showed no growth. Viral markers, autoimmune profile, C and p ANCA were all negative apart from a raised serum IgG level. Ultrasound abdomen showed a hyperechoic liver with an enlarged spleen along with splenic varices and minimum ascites. Ultrasound hepatic doppler was normal. Serum AFP levels were normal while workup for Wilson's disease was negative. Fibroscan showed F4 fibosis. CT scan abdomen showed an enlarged left lobe of the liver along with an enlarged spleen. His EGD revealed varices. So liver biopsy was done that was suggestive of chronic granulomatous disease with ZN stain testing negative for TB.PPD, urine for AFB were both negative. Serum ACE levels were raised. He started ATT therapy but his condition did not improve. So, on the suspicion of hepatic sarcoidosis, he started on steroids and had a drastic improvement in his condition.

Hepatic sarcoidosis: pathogenesis, clinical context, and treatment options

Sarcoidosis is typically characterized as a non-caseating granulomatous disease that has the ability to affect multiple different organ systems. Although extra-thoracic sarcoidosis can occur in the presence and also without lung involvement, isolated extra-pulmonary disease is rare. The liver is the third most commonly affected organ system after the lungs and lymph nodes. When discussing hepatic sarcoidosis it is important to keep in mind that many patients in this population may not present as one would typically expect since most of the patients are asymptomatic or have mild presentations. Therefore, the diagnosis can be difficult at times since no single laboratory or imaging study can definitively diagnose this systemic disease. In the rare case of some patients where there is difficulty in discerning between different pathologies, the use of image-guided tissue biopsy may be necessary to establish a diagnosis. At the current time, there are no clear guidelines for the management of hepatic sarcoidosis and are mostly dependent on a patient's clinical status at time of presentation. The current body of research in regard to treatment suggests steroids to be the mainstay of therapy. However, there is a role for additional immunosuppressive therapy in cases where the initial treatment is refractory to steroids. In this manuscript, we discussed the pathogenesis of liver sarcoidosis and context of its presentation. In addition, the differential diagnosis and imaging evaluation in this population is discussed. Finally, treatment options are reviewed in setting of previous studies for liver sarcoidosis.

[Many faces of sarcoidosis]

Sarcoidosis is a systemic, inflammatory, granulomatous disease of unknown origin that can involve any organ. More than 90% of patients have thoracic sarcoidosis, which most frequently presents with bilateral hilar lymphadenopathy. In approximately 20% of patients with thoracic sarcoidosis there is involvement of the lung parenchyma as well as mostly asymptomatic cardiac sarcoidosis in up to 55% of patients. Most patients are asymptomatic and the diagnosis is an incidental finding on chest X-ray or during clarification of unspecific symptoms, such as fatigue or cough. In approximately two thirds of patients the disease undergoes spontaneous remission and in one third the disease follows a chronic or even progressive course. Furthermore, sarcoidosis can also be manifested in the abdominal organs, the central nervous system (CNS) and the musculoskeletal system. These manifestations are frequently subclinical and require targeted diagnostics when sarcoidosis is clinically suspected.