Gastrointestinal sarcoidosis is a rare disease with only twenty-five histologically confirmed reported cases. A patient is reported who presented with dysphagia secondary to gastrointestinal sarcoidosis. A 51-year-old African-American women presented with a 6 month history of intermittent, non-progressive dysphagia for solids and liquids, with no difficulty in initiating swallowing. Patient denied odynophagia, pyrosis, weight loss, regurgitation of food, nausea or vomiting, early satiety, change in bowel habits, or rectal bleeding. She had a history of dry cough for one year. She had a recent normal screening colonoscopy. Physical examination was normal, with no oral ulcers, palpable adenopathy, or rash. Lungs were clear to auscultation and percussion. There were no focal neurological deficits. Laboratory tests revealed normal hemogram and normal electrolyte levels. The corrected calcium level was 9.2 mg/dl, the rapid plasma reagin (RPR) was negative, the PPD (purified protein derivative) was non-reactive, and the serum angiotensin converting enzyme level was elevated at 48 U/L. Barium swallow revealed absent primary peristaltic waves, and disordered esophageal motility. There was mild, focal, persistent, narrowing of the distal esophagus. Esophagogastroduodenoscopy revealed a normal appearing esophagus and diffuse gastritis with antral nodules. Pathologic examination of biopsies of the antral nodules showed multiple well-formed noncaseating granulomas in the submucosa (Figures 1 & 2), with no acid-fast bacilli, fungal organisms, or Helicobacter pylori detected. Chest roentgenogram showed increased prominence of perihilar markings, Chest computed tomography showed patchy parenchymal density with nodularity extending laterally in the right upper lobe and right apex, and fibronodular density in the right middle lobe, findings consistent with sarcoidosis (Figure 3). After gastric sarcoidosis was diagnosed, prednisone treatment 40 mg daily was initiated. The patient reported significant symptomatic improvement after 8 weeks of therapy. In this case, patient race, age, sex and history of dry cough provided clues to the diagnosis. Other etiologies of noncaseating granulomas, including syphilis, H. pylori infection, and Crohn's disease, were excluded. The currently reported unusual presentation of sarcoidosis demonstrates that sarcoidosis can initially present with dysphagia, and gastrointestinal sarcoidosis should be considered in patients presenting with dysphagia in the appropriate clinical setting.Figure: Medium power photomicrograph of gastric submucosa, showing noncaseating granulomas.Figure: High power photomicrograph of gastric submucosa, showing noncaseating granulomas.Figure: Chest computed tomography showing patchy parenchymal density in the right middle pulmonary lobe.
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Jun 8, 2018
William Makis + 3
Open Access
