Asymptomatic Transaminitis: A Case of Hepatic Sarcoidosis

Abstract

Background: Sarcoidosis is a chronic inflammatory multisystem disease characterized by the presence of non-caseating granulomas. Pulmonary involvement is most common, however hepatic manifestations occur in up to 70% of cases.1 We present a patient with asymptomatic transaminitis who was found to have isolated hepatic sarcoidosis, a rare diagnosis. Case: A 47 year old female with a PMH of cholecystitis status post cholecystectomy, iron deficiency anemia and history of migraines presented for evaluation of abnormal liver enzymes. Labs were notable for AST 50-70s, ALT 60-80s, and ALP 122. She reported intermittent fevers, once a week, ranging from 99 - 101F, but denied chills or night sweats. Abdominal ultrasound and CT scan revealed peripancreatic and porta hepatis lymphadenopathy. PET scan showed increased uptake in corresponding regions. Inflammatory markers were elevated (CRP 21 and ESR 112). Hematologic work-up was unremarkable for malignancy or lymphoma. She underwent extensive serologic evaluation, which was unremarkable for autoimmune or infectious etiologies. Left lobe liver biopsy was performed after which patient started oral prednisone therapy. Biopsy results showed multiple non-caseating granulomas in portal and lobular distribution with mixed portal and periportal inflammation, as well as bile duct injury and lesions without evidence of fibrosis, steatosis, copper deposition, or stainable microorganisms. On follow-up, there was no significant improvement in transaminitis. ACE level elevated to 73. Steroids were discontinued and she is now being managed conservatively for hepatic sarcoidosis with close follow-up and discussion of long-term immunosuppressive therapy. Discussion: The etiology of sarcoidosis is still not well understood and presentations with only hepatic involvement are uncommon. This case demonstrates that isolated hepatic sarcoidosis, while a rare diagnosis, should be considered in asymptomatic patients with abnormalities in liver function tests whose preliminary laboratory and imaging work-up has been unrevealing. Serum ACE levels along with liver biopsy for histopathology provides a diagnostic clue. Management options include close medical observation, prednisone and/or ursodeoxycholic acid, as well as initiation of immunosuppressive agents.