2101 Non-Necrotizing Granulomas of the GI Tract and Abdominal Lymph Nodes. Crohn’s Disease, Sarcoidosis or Both?

Abstract

INTRODUCTION: Digestive tract involvement of sarcoidosis is rare (<2%) with few case reports of gastric and colon involvement and requires the presence of non-necrotizing granulomas. Non-necrotizing granulomas of the GI tract are typically associated with either Crohn’s disease or sarcoidosis. Distinguishing between the two can be a diagnostic dilemma. CASE DESCRIPTION/METHODS: A 25 y.o African American male presented with nausea, vomiting and weight loss. CT showed diffuse nodular airspace disease, lymphadenopathy, and thickening of the antrum and proximal duodenum. Lymphadenopathy involved the porta hepatis, stomach, head of the pancreas, abdominal mesentery, retroperitoneum and groin. EGD/EUS revealed mild erosive gastritis and duodenitis. Gastric and duodenal biopsies revealed non-necrotizing granulomas. Lymph node FNA showed reactive lymphocytes and non-necrotizing granulomas. Flow cytometry was normal. Colonoscopy with biopsy found nodular lymphoid hyperplasia in the terminal ileum (TI). Serum ACE level, lysozyme, and IgG4 were normal. IgG 3 was elevated. PFTs showed mildly reduced DLCO. Infectious work up was negative. He was treated with steroids and improved clinically. Three years later he presented with recurrent epigastric pain, anorexia, early satiety and profound weight loss. CT revealed increased abdominal lymphadenopathy. EGD showed inflammation and thickening of the stomach and duodenum. CSY revealed TI lymphoid hyperplasia, erosions over the IC valve and mild right sided colitis (Figure 1). Histology showed non-necrotizing granulomas with acute/chronic inflammation in the right colon, duodenum and stomach. CT chest showed regression of findings compared to 2016. Work-up revealed normal amyloid, ACE and soluble IL2 Ab receptor. Hypergammaglobulemia and hypoalbuminemia were present. He was treated with prednisone with rapid improvement. DISCUSSION: Our case demonstrates difficulty clarifying the diagnosis of non-necrotizing granulomas and distinguishing between atypical Crohn’s and sarcoidosis. Evidence of pulmonary involvement, low DLCO, lymphadenopathy and hypergammaglobulinemia argue in favor of sarcoidosis. Progression of inflammation to the TI and colon suggest Crohn’s. Pathology noted that granulomas were more abundant than commonly seen with Crohn’s disease alone. Additionally, there was more background inflammation than typically seen in GI sarcoid alone. A multidisciplinary team determined that this was consistent with Crohn’s and sarcoidosis occurring concomitantly.