S3226 Hepatic Sarcoidosis Manifesting as Asymptomatic Elevation in Liver Enzymes

Abstract

Introduction: Sarcoidosis is a systemic disorder of unknown etiology characterized by the formation of non-caseating granulomas and can affect any organ in the human body. The most frequently involved organs are lungs and hilar lymph nodes; however, involvement of the liver has been described in prior literature. The spectrum of hepatobiliary involvement can range from asymptomatic hepatic granulomas, and minimally deranged LFTs to symptomatic disease complicated with cholestasis, portal HTN, and cirrhosis. We report a case of asymptomatic LFT elevation in a patient with a prior history of sarcoidosis. Case Description/Methods: An 82-year-old African American woman with a past medical history of coronary artery disease, hyperlipidemia, hypertension, Asthma, and Sarcoidosis presented with asymptomatic elevated LFTs discovered by her PCP. The patient denied any complaints from the GI or any other organ system standpoint. Prior blood transfusions, needle sharing, IV drug use, excessive alcohol use, herbal/alternative medicine use, recent changes in medications, or suicidal ideation were ruled out by meticulous history taking. Initial AST, ALT, ALP, GGT, T. bilirubin, and CK measured 783, 532, 1041, 443, 1.6, and 5,699, respectively. (Table 1) Imaging ruled out gallstone and intra-abdominal pathologies, prompting further investigation of possible infiltrative/infectious/autoimmune/neoplastic etiology. Subsequent laboratory findings ruled out thyroid abnormalities, viral or toxic hepatitis, hemochromatosis, Wilson’s Disease, autoimmune hepatitis, and primary biliary cholangitis. The liver biopsy showed granulomatous hepatitis and noncaseating (non-necrotizing) epithelioid granuloma favoring sarcoid deposition (Figure 1). Discussion: This case highlights the importance of considering hepatic sarcoidosis as a potential cause of LFT elevation, especially in a patient with a prior history of sarcoidosis. In such patients, after common causes of LFT elevations have been ruled out based on the patient’s history, imaging, blood tests, and screening for autoimmune diseases, liver biopsy should be considered earlier in the management course to reach a timely diagnosis. This is especially important as not all cases of hepatic sarcoidosis require treatment, so considerations for treatment vs. closer follow-up could be decided as soon as the liver biopsy results are available. This would significantly decrease the burden on healthcare resources by avoiding unnecessary testing and aiding in timely and accurate management.Figure 1.: Liver Biopsy Results. Table 1. - LFT trend Test name Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day of discharge AST 783 673 566 469 429 355 267 237 ALT 532 441 395 335 330 284 238 224 ALP 1041 920 898 822 780 715 631 653 Total Bilirubin 1.6 1.5 1.3 1.0 0.9 0.9 0.9 1.0 CK 5699 4154 3225 2721 2378 1402 725 437