The George Washington University Hospital Washington, DC, United States
Joseph Cioffi, MD1, Atoosa Rabiee, MD2, Wen Chen, MD2, Jill P. Smith, MD2 1The George Washington University Hospital, Washington, DC; 2Washington DC Veterans Affairs Medical Center, Washington, DC
Introduction: Sarcoidosis is a systemic granulomatous disease which may involve the liver in ~11.5% of cases. Coronavirus disease 2019 (COVID-19) can induce a systemic, pro-inflammatory state but the development of systemic sarcoidosis after COVID-19 has not been described. We present the case of a newly diagnosed systemic sarcoidosis after COVID-19 infection.
Case Description/Methods: A 50 year old male patient was evaluated for increased liver enzymes. He had a history of familial hypercholesterolemia, fatty liver disease, and diabetes mellitus. Seven months prior he was admitted to the hospital with shortness of breath, cough, lightheadedness, nausea and was diagnosed with COVID-19. After recovery, he developed pleurisy. CT scan showed mediastinal lymphadenopathy and scattered nodules. PET scan showed uptake concerning for reactive nodes, chronic granulomatous disease or lymphoproliferative disease. Subsequent lymph node aspirate found noncaseating granulomas consistent with sarcoidosis. He was referred to hepatology for abnormal liver enzymes (ALT 104, AST 81, Alkaline Phosphatase 216, Total Bilirubin 1.1). Tests for viral/autoimmune hepatitis, AMA, ANA, hemochromatosis, A1AT and ceruloplasmin were negative. Liver US showed steatosis and no evidence of obstruction. Transient elastography by FibroScan confirmed steatosis, CAP score of 347 and stiffness of 28kPa consistent with cirrhosis or infiltrating disease. Liver biopsy (Figure 1) revealed marked granulomatous inflammation with 10-20% macro/micro-steatosis and stage 2-3 portal fibrosis. AFB stains were negative. Given the marked inflammation and fibrosis, the patient was started on prednisone 40mg daily with 4 week labs showing liver enzyme improvement (ALT 80, AST 31, Alk Phos 149, T Bili 0.6). Prednisone resulted in hyperglycemia requiring insulin, so azathioprine was started as steroid sparing treatment with budesonide added which he tolerated well.
Discussion: Multisystem inflammatory syndrome in adults (MIS-A) is a rare complication of COVID-19. This case represents a unique type of MIS-A with hepatic sarcoidosis. The liver may be affected during COVID-19 with liver enzymes elevation reported in 20–30% of those with acute infection. After recovery, persistent elevation in hepatic transaminases and alkaline phosphatase should alert the clinicians to investigate for MIS-A triggered diseases such as sarcoidosis.
Joseph Cioffi indicated no relevant financial relationships.
Atoosa Rabiee indicated no relevant financial relationships.
Wen Chen indicated no relevant financial relationships.
Jill Smith indicated no relevant financial relationships.
Joseph Cioffi, MD1, Atoosa Rabiee, MD2, Wen Chen, MD2, Jill P. Smith, MD2. P2917 - Hepatic Sarcoidosis Diagnosis After COVID-19 Infection, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.