Acute Cholecystitis as an Extrapulmonary Manifestation of Sarcoidosis: A Rare Clinical Presentation

Abstract

Sarcoidosis is a systemic granulomatous process of unknown cause. Pathologically, it is characterized by noncaseating granulomas, and in more than 90% of patients, the lungs are affected. In rarely involves the gallbladder. The finding of noncaseating granulomas is nondiagnostic as other granulomatous diseases are more likely to be found in the GI tract. Although rare, GI tract granulomas likely represent sarcoidosis when prior diagnosis is confirmed. We present a patient with acute cholecystitis secondary to sarcoidosis. A 66-year old male with a history of pulmonary sarcoidosis presented with intermittent biliary colic of two weeks. He admit to worsening right upper quadrant pain two days prior to admission, with nausea and vomiting related to meals. He denied changes in bowel movements, jaundice, or exposure to hepatotoxins. Medical history included untreated pulmonary sarcoid, as he was lost to follow-up after initial diagnosis. He denied prior surgeries, smoking, drug use, travel or new sexual partners. Localized tenderness below the right costal margin was present on physical exam. Laboratory studies disclosed normal CBC, lipase of 67, and normal liver function tests. HbsAg and AntiHCV were negative. ACE level was elevated 78 and calcium normal. Right upper quadrant ultrasound demonstrated cholelithiasis with gallbladder wall thickening suggestive of acute cholecystitis. The patient underwent laparoscopic cholecystectomy and symptoms resolved. During surgery, a dilated gallbladder and a large node of Calot, the sentinel lymph node of the gallbladder, were resected. Histologically, numerous noncaseating granulomas were found within the gallbladder and Calot's node. A diagnosis of extra-pulmonary sarcoidosis was confirmed. Sarcoidosis involving the gallbladder is not well described in the literature as it is rare. The involvement of Calot's node and extrinsic compression of the cystic duct by the granulomatous lymph node likely led to cholecystitis. Whether disease can regress spontaneously or with steroid therapy is unknown. There no confirmatory test for sarcoidosis and diagnosis involves excluding other causes of granulomatosis, such as infection. Crohn's was unlikely as pulmonary disease is statistically rare. It is important to consider sarcoidosis as a systemic syndrome. Gallbladder involvement, though rare, is important to consider in patients with a history of sarcoidosis and complaints suggestive of biliary colic.