De Novo Pulmonary Sarcoidosis in a Liver Transplant Patient

Abstract

SESSION TITLE: Fellow Case Report Slide: Pulmonary Manifestations of Systemic Disease SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Sunday, October 23, 2016 at 10:45 AM - 12:00 PM INTRODUCTION: Sarcoidosis is a granulomatous disease affecting multiple organs including but not limited to the lungs, heart, and skin. IL-2 is thought to be implicated in the pathophysiology of sarcoidosis; hence inhibitors of IL-2 production should theoretically reduce the incidence of sarcoidosis CASE PRESENTATION: 62-year-old man with a history of hepatitis C virus (HCV) infection underwent an orthotropic liver transplantation in 2011 and presented 4 years later with worsening cough, dyspnea, and fatigue for 8 months. Additional symptoms included a macular rash on the knees, and a transient hemianopia. A PET-CT scan revealed multiple FDG-avid lymph nodes in the mediastinum and retroperitoneum and FDG-avid lesions in the left gluteal, subpleural, and bibasilar areas. An excisional biopsy of the left gluteal lesion revealed multiple non-caseating granulomas. Bronchoalveolar lavage and transbronchial tissue stains and cultures were negative for bacterial or fungal organisms. Transbronchial biopsy of the left lower lobe revealed non-necrotizing granulomas. Review of the pre-liver transplant liver biopsy did not reveal any granulomas. The patient was diagnosed with de novo pulmonary sarcoidosis with cutaneous involvement. The patient was started on prednisone 20 mg daily after which symptoms improved significantly on his first follow-up visit DISCUSSION: To our knowledge, this is a rare case of de novo sarcoidosis involving the lungs and other extrahepatic organs despite inhibition of IL-2 with tacrolimus.Granulomas have been reported in both native and allograft livers of patients with chronic HCV infection but there has been no report of extrahepatic granulomas attributed to HCV. We postulate that HCV infection might be involved in an alternative immunologic pathway leading to the development of extrahepatic sarcoidosis CONCLUSIONS: The incidence of de novo extrahepatic sarcoidosis after liver transplant is rare, but clinicians should be aware of this condition in this subset of patients Reference #1: Cengiz C, at al. (2005) Recurrent hepatic sarcoidosis post-liver transplantation manifesting with severe hypercalcemia: a case report and review of the literature. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society 11 (12):1611-1614 Reference #2: Chest. 2003;124(4_MeetingAbstracts):259S Reference #3: Vakiani E, et al. Hepatitis C-associated granulomas after liver transplantion: morphologic spectrum and clinical implications. Am J Clin Pathol 2007;127:128-134 DISCLOSURE: The following authors have nothing to disclose: Ghassan Kamel, Vinit Patil, Setu Patolia, Joseph Roland Espiritu No Product/Research Disclosure Information