A Case of Sarcoidosis Presented Initially with Abnormal Liver Chemistry and Subsequently Developed Pulmonary Symptoms

Abstract

Introduction: Sarcoidosis is a multisystem disease characterized by the presence of non-caseating granulomas in affected tissue. The common age of presentation is 20-40 years. Black people are three to four times more likely to have sarcoidosis, and may have more severe disease than Caucasians. Gastrointestinal tract involvement in sarcoidosis is rare, while liver involvement is common, following lung and lymph nodes. Up to 35% of patients with sarcoidosis have abnormal liver tests, and about 60% of patients with hepatic involvement have symptoms of fever, night sweats, anorexia, and weight loss. Case: We present a case of a 53-year-old male with comorbidities of hypertension, diabetes mellitus, and dyslipidemia, who initially presented with elevated blood glucose level. Liver tests were noted to be abnormal (elevated alkaline phosphatase (1021 U/L), and transaminases (AST 71 U/L and ALT 131 U/L). Further work-up, including hepatitis panel, ANA, ASMA, and AMA were negative. Chest X-ray, echocardiogram, abdominal ultrasound, and MRCP were negative for any acute pathology. Needle biopsy of liver revealed liver parenchyma with rare aggregates of histiocytic cells, consistent with non-nectrotizing granuloma. He presented six months later with persistent cough for more than a month. In view of recent abnormal liver biopsy, CT scan of the chest was done, which revealed multiple parenchymal and subpleural nodules in a perilymphatic distribution, consistent with sarcoidosis. Whole body gallium scan showed abnormal uptake visualized in both hila and lungs, consistent with active sarcoidosis. Angiotensin converting enzyme (ACE) level, which was initially normal (39 U/L), was found to be elevated (117 U/L) when patient presented with pulmonary symptoms. He was started on prednisone, and the pulmonary symptoms, as well as liver enzymes, improved significantly (alkaline phosphatase 170 U/L, AST 16 U/L and ALT 29 U/L) on follow-up visits.Figure: Liver biopsy showing hepatic parenchyma with non-necrotizing epithelioid cell granuloma.Conclusion: This is an interesting case of an adult male who initially was diagnosed to have hepatic sarcoidosis without symptoms and signs of portal hypertension. He eventually had pulmonary involvement with symptoms.