2573 Appendicitis—Think Sarcoidosis? Appendicular Sarcoidosis Presenting as Acute Appendicitis

Abstract

INTRODUCTION: Sarcoidosis is a chronic inflammatory multisystem disease. Organs typically affected include the lungs, lymph nodes and skin. Gastrointestinal involvement although not uncommon, is usually asymptomatic. Stomach is the most commonly involved gastrointestinal organ, but esophagus, appendix, colon, and rectum have also been implicated. Symptomatic appendicular sarcoidosis is extremely rare. We present a rare case of symptomatic appendicular sarcoidosis. CASE DESCRIPTION/METHODS: A 49 year old woman with a history of chronic low back pain and recurrent kidney stones presented to the office with vague abdominal pain for 3 days. Exam revealed a right iliac fossa tenderness. Lab work was significant for mild anemia (Hemoglobin 11 gm/dl) and elevated ESR (30 mm/hr). A CT abdomen showed acute appendicitis, and detected an appendicular mass. A prior MRI of the spine had shown a suspected metastatic lesion. CT chest revealed mediastinal lymphadenopathy, and a spiculated lung nodule. Laparoscopic appendectomy was performed, and the pathology revealed non-necrotizing granulomas raising suspicion for sarcoidosis. Bronchoscopic ultrasound-guided biopsy of the lymph nodes also revealed granulomas. Serum angiotensin converting enzyme levels were elevated (68 U/L). The patient's symptoms improved following initiation of corticosteroids. DISCUSSION: There are a number of differentials for granulomatous inflammation of the appendix, notably Crohn's disease, tuberculosis, histoplasmosis and Yersinia pestis infection. 1 Appendicular involvement of sarcoid is very rare and is most often diagnosed incidentally on a PET scan. The clinical presentation of appendicular sarcoidosis may range from pain to perforation and abscess formation. 2 Surgical intervention should not be delayed in patients with sarcoidosis presenting with right iliac fossa pain as there is a high risk of perforation. Such a systemic disease process typically involves other organs, and can be relatively controlled with systemic steroids.