Isolated hepatic sarcoidosis mimicking liver microabscesses: a case report

Abstract

Sarcoidosis is a systemic inflammatory disorder of unknown etiology characterized by the formation of noncaseating granulomas in the involved tissues and lymph nodes. It usually involves multiple organs, including the lungs, skin, bones, muscles, eyes, heart, liver, spleen and lymph nodes [1]. Although liver is an important site of sarcoidosis, isolated hepatic involvement is quite rare [2]. In this paper it is aimed to present a case of sarcoidosis with isolated liver microabscesses. A 51-year-old woman with no known prior disease admitted to our outpatient clinic with the complaints of fever persisting for 20 days and abdominal pain. In the physical examination her length was 150 cm and her weight was 65 kg. She had fever (38 C) and abdominal tenderness on palpation in the upper right quadrant. She had malaise and 8 kg weight loss within the previous month. Her main laboratory findings were: hemoglobin 9.7 g/dl, leukocyte 15.57 9 10/mm, neutrophil 80.9 %, C reactive protein 31 mg/dl and erythrocyte sedimentation rate (ESR) 104 mm/h. Abdominal ultrasonography revealed a 14 mm hemangioma in the segment 6 and a 42 9 38 mm cystic lesion nearby the gallbladder. Contrast enhanced abdominal computed tomography (CT) demonstrated diffuse hypodense infiltrative lesions in the liver representing microabscesses (Fig. 1a). At the same time liver magnetic resonance imaging (MRI) was performed to better characterize the liver lesions and revealed isointense and intermediate hyperintense signal changes on T2weighted images and iso-hypointesity on T1-weighted images. Postcontrast T1-weighted images showed diffuse hypointense lesions and rim enhancement representing microabscesses. There were nonspecific nodules with a size of max 3.5 mm at upper lobe of the left lung in chest CT, and there was no mediastinal lymphadenopathy. Blood cultures were performed. Empirical ceftriaxone and metronidazole were started. Serologic tests for Echinococcus, fasciolasis, toxoplasmosis, leishmaniasis, HIV and brucellosis were negative. Since there was no clinical response on day 5, treatment was switched to meropenem and teicoplanin combination. There was no cardiac vegetation in transthoracic and transesophageal ECHO cardiography and no pathologic finding in electrocardiography. Autoimmune markers (ANA, ASMA, LKMA, ANCA) were negative. Tumor markers were normal. Blood or urine cultures did not reveal any bacterial or mycobacterial growth. Quantiferon TB Gold test was negative, tuberculosis skin test resulted in an induration of 9 mm, and blood adenosine deaminase was 13.3 U/l. CD4/CD8 rate was normal in bronchoalveolar lavage (BAL). BAL cytology revealed 95 % macrophages, 4 % lymphocytes and 1 % neutrophils. Bacteriological or mycobacteriological cultures of BAL did not reveal any pathogen. Liver biopsy and aspiration from the cyst were performed and Entamoeba hystolytica M. I. Tasbakan (&) H. A. Erdem H. Pullukcu T. Yamazhan O. R. Sipahi B. Arda S. Ulusoy Department of Infectious Diseases and Clinical Microbiology, Medical Faculty, Ege University, Izmir, Turkey e-mail: tasbakan@yahoo.com