Samuel Igbinedion, MD1, Omar Khan, MD2, Rajib Gupta, MD2, Ioannis Papayannis, MD2 1LSU HSC Shreveport, Shreveport, LA; 2Louisiana State University Health Sciences Center, Shreveport, LA
Introduction: Sarcoidosis is a granulomatous disorder that can involve multiple organs and can present with a variety of different symptoms. The case below describes a unique situation where a patient presented with new-onset ascites that was later found to be due to sarcoidosis.
Case Description/Methods: A 46-year-old female with a past medical history of diabetes and hypertension presented with new large-volume ascites. The initial CT of the abdomen/pelvis showed hepatosplenomegaly with no evidence of portal vein thrombosis. An extensive work up for cirrhosis was negative for autoimmune, rheumatologic, or infectious etiologies. Labs were significant for a mild transaminitis, hyperbilirubinemia of 7.8, and a significantly elevated alkaline phosphatase of 985. MRCP did not have any remarkable findings. Peritoneal fluid analysis was consistent with portal hypertension. She was started on diuretics but despite maximizing the doses, the patient continued to have significant ascites on follow-up visits. As she required a weekly paracentesis with removal of more than 10 liters each time, she underwent a TIPS with improvement. On repeat labs, there was improvement in her bilirubin and transaminases, but the alkaline phosphatase remained elevated. A biopsy of the liver was done, showing non-caseating granulomas with mild fibrosis. Because the initial chest x-ray did not show any findings and because isolated liver sarcoidosis is rare, ursodiol was started for presumed PBC. The patient reported worsening weakness and severe pruritus on follow-up visits, with the alkaline phosphatase remaining elevated at 600. A chest x-ray 3 months after the initial presentation showed developing mediastinal lymphadenopathy. An ACE level was checked and was elevated at 177, despite the patient being on an ACE inhibitor. These findings, along with the pruritus, prompted treatment for sarcoidosis. Steroids were avoided due to uncontrolled diabetes, so the patient was started on azathioprine. Within 1 month, the patient became asymptomatic with significant improvement in her labs.
Discussion: Sarcoidosis does involve the liver in about 60% of patients, but only 5% of patients with liver involvement are symptomatic. Symptoms usually include abdominal pain and pruritus. This case should raise awareness of the atypical presentations of sarcoidosis, such as the massive and refractory ascites with pruritus in this patient, so that an early diagnosis could be made to prevent the progression of the disease to states such as cirrhosis.
Figure: Figure 1: Skin lesions due to pruritus Figure 2: Initial CT abdomen/pelvis coronal view Figure 3: Initial CT Abdomen/pelvis transverse view Figure 4: Non-caseating granuloma on pathology Figure 5: Non-caseating granuloma on pathology
Disclosures: Samuel Igbinedion indicated no relevant financial relationships. Omar Khan indicated no relevant financial relationships. Rajib Gupta indicated no relevant financial relationships. Ioannis Papayannis indicated no relevant financial relationships.
Samuel Igbinedion, MD1, Omar Khan, MD2, Rajib Gupta, MD2, Ioannis Papayannis, MD2. P1847 - A Diagnostic Dilemma: Massive and Intractable Ascites Due to Hepatic Sarcoidosis, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.