Hepatic Sarcoidosis Suspected for Liver Cirrhosis - A Case Report of Diagnosing Subclinical Disease

Abstract

Sarcoidosis is a granulomatous disease with systematic involvement and unknown etiology. The pathologic hallmark is non-caseasting granulomas in involved tissues. The majority of patients have pulmonary manifestations, however, up to 30% present with extrathoracic disease. Symptomatic liver involvement is estimated to occur in 5 to 15 percent of patients with sarcoidosis, while much higher rates of subclinical involvement are suspected to go undiagnosed. We describe a 53-year-old white male who presented for evaluation prior to renal transplant. His past medical history was significant for sarcoidosis, ESRD secondary to IgA nephropathy, hypertension, morbid obesity, history of heavy alcohol use and suspected liver cirrhosis based on CT scan of 3-year duration. On review of systems, he denied fever, night sweats, unintentional weight loss, lymphadenopathy, hematemesis, melena, abdominal distension and history of confusion. Physical examination was unremarkable with no evidence of icterus, hepatomegaly, splenomegaly, or abdominal masses. He denied family history of liver disease and denied history of cigarette smoking and IV drug use. On laboratory testing, he is EBV positive, whereas viral hepatitis panel, CMV and ANA were negative. He had a normal complete blood count, basic metabolic panel and liver panel including AST, ALT, Alkaline phosphatase, PT/INR and platelet count. Ferritin, serum iron, TIBC, Fe saturation, UIBC were within normal limit. He had a negative TB quantiferon. Abdominal CT scan without contrast showed morphologic features of liver cirrhosis with small upper abdominal collaterals and mild splenomegaly, calcified porta hepatis and portacaval lymph nodes, with small notable retroperitoneal lymph nodes. A Liver core biopsy was done revealing reveal non-caseating granulomas consistent with clinical history of sarcoidosis, no evidence of cirrhosis, and unremarkable PAS stain with and without diastase, reticulin stain, trichrome stain, and iron stains. In sarcoidosis, liver involvement is common reaching 50 to 65 percent of patients, however, only 5 to 15 percent of patients have symptoms and many remain undiagnosed. Therefore, accurate history, laboratory testing and imaging are important in identifying those patients to determine monitoring and treatment plans. Sarcoidosis is an important differential for hepatic lesions and should be highly suspected especially in patients with pre-existing sarcoidosis, even with normal laboratory testing.