Dear Sir,
A 33-year-male presented with complains of fever, weight loss and abdominal discomfort for one year. Abdominal examination showed mild hepatomegaly there was no palpable lymph nodes.
His prior evaluation included, bilateral hilar lymphadenopathy on chest X-ray, hepatosplenomegaly and multiple retroperitoneal lymph nodes on an abdominal ultrasound. A contrast CT of abdomen showed multiple hypodense lesions in liver and spleen, multiple lymph nodes were found in peri-pancreatic, para-aortic and precaval regions measuring from two centimeters to four centimeters in size. Before presenting to us, he was treated elsewhere with anti-tuberculous therapy for eight months on the basis of granulomas in FNAC from abdominal lymph nodes with no clinical response.
Liver function tests showed alkaline phosphatase (ALP) of 430 IU/L (30–120) and gamma glutamyl transferase (GGT) of 184 IL/L (7–50), bilirubin and aminotransferases were normal. Serum angiotensin converting enzyme levels were 215.2 (20.0–70.0), liver biopsy confirmed presence of multiple non-caseating granulomas (Figure 1).
Figure 1.
Non-caseating granulomas in the liver biopsy (black arrows).
He was therefore diagnosed with sarcoidosis and treated with corticosteroids, he continues to do well on follow up of more than a year with improvement of biochemical abnormalities and clinical improvement.
Liver involvement in sarcoidosis has been reported in the range of 5–30% in various studies.
In a population based retrospective study from the U.S., the prevalence of liver involvement was found in 6% of patients with sarcoidosis, being a population based follow up study, this prevalence is likely to be representative.1
Liver involvement in sarcoidosis is usually asymptomatic and may manifest as abnormal liver enzymes mostly ALP and GGT, aminotransferases may be normal or only slightly abnormal, imaging findings include hepatomegaly or hypodense lesions in the liver. Rarely, there may be progression of liver disease with portal hypertension and its manifestations.2
Diagnosis of sarcoidosis needs multisystem involvement with histologic evidence from one organ and exclusion of other causes of hepatic granuloma such as primary biliary cirrhosis.3 Serum ACE levels may be normal in as many as 40% patients with liver involvement.1
To conclude, sarcoidosis is an important cause of infiltrative liver disease and must be kept in the differential diagnosis of such patients.
References
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