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The Great Mimicker Strikes Back. Could we have caught it sooner?

CASE: A 43 year-old Caucasian male with past medical history of CKD stage 5, CAD, with a previous
hospital admission where he was found to have low serum-ascites albumin gradient (SAAG), high
protein ascites, presented with chronic, progressive, constant, shortness of breath and malaise. He also
had constant vague generalized abdominal discomfort that is non-radiating with associated nausea and
vomiting. Laboratory testing showed hyponatremia, normocalcemia, pancytopenia, microcytic
anemia, hypoalbuminemia, (elevated bilirubin). Further work up revealed significant elevation of
alkaline phosphatase and NO ELEVATIONS IN LIVER ENZYMES (AST/ALT). Sputum gram stain revealed
gram positive cocci, few gram negative rods, moderate yeast. CT of the chest revealed cardiomegaly
with TRACE PLEURAL EFFUSIONS, left lower lobe airspace consolidation, mediastinal
lymphadenopathy. Abdominal CT demonstrated splenomegaly and CIRRHOTIC LIVER. Ultrasound
guided needle biopsy of the liver revealed multiple small non-necrotizing granulomas. Portal triads
appeared normal without inflammation. No organisms were identified on special stains for acid-fast
bacilli and fungus.

[The patient clinically improved with oral steroids??? What was the management??]

The hospital course was significant for (PNEUMONIA treatment???). Paracentesis of the ascites was
performed and was negative for malignant cells. (Mesothelial cells and chronic inflammatory cells were
present??? Need this?? )

DISCUSSION Sarcoidosis is a multisystemic granulomatous disease of unknown etiology. While the liver
is involved in the majority of patients, symptomatic hepatic sarcoidosis only occurs in 5 to 15 percent
of cases. (patients are often asymptomatic). Splenomegaly occurs in about 20% of patients and can
lead to leukopenia, anemia, and thrombocytopenia. Ascites in sarcoidosis is rare. Our patient had a
recurrent history of ascites secondary to liver cirrhosis; a possible complication from long-standing
hepatic sarcoidosis. The liver biopsy revealed granulomatous hepatitis which was consistent with
clinical suspicion of sarcoidosis. The confirmatory diagnosis is histopathology demonstrating non-
caseating granulomas in the liver.

Additionally, our patient had evidence of pleural effusion, most likely due to decreased oncotic pressure,
secondary to chronic liver cirrhosis. The pleural effusion eventually led to (clinical suspicion of
pneumonia) evidence of lower lobe consolidation pneumonia (at presentation).

Mediastinal lymphadenopathy was identified on CT of the thorax

-or…. Our patient was originally thought to have (pneumonia??)
Along with laboratory finds as hypoalbuminemia and hyperbilirubinemia, there was significant data
for elevated alkaline phosphatase. Only 15% of patients with sarcoidosis are ultimately found to have
isolated elevated alkaline phosphatase.
(This case had atypical liver enzymes)

-Laboratory findings consistent with (chronic) liver cirrhosis (hypoalbuminemia, elevated bilirubin)

(….this constellation of findings supports) a diagnosis of sarcoidosis

Previous serologic liver work-up and cardiac work up was nondiagnostic.

CONCLUSION:….. MAYBE need it??

We present this case to illustrate (liver cirrhosis) masquerading as ascites in the setting of undiagnosed
sarcoidosis. (sarcoidosis of the liver can mimic liver cirrhosis, which manifested cirrhosis complications.

Sarcoidosis is commonly a disorder frequently encountered by physicians and it often has multisystem
clinical presentation.

This case was unique in that it showed atypical presentation of ascites, pancytopenia, initially thought to
be due to possible (Tuberculosis/fungal/cardiac source

The differential diagnosis must be broadened and further workup should be initiated. This case
highlights a rare initial presentation of hepatic sarcoidosis with atypical serological liver workup and
(cardiac workup) that was nondiagnostic.

This case highlights the importance of understanding and keeping a high suspicion for sarcoidosis on
the differential diagnosis with liver involvement.

, which can present itself with many different clinical manifestations (ways).

“which can present itself in many different ways”

Physicians should recognize/think of differential diagnosis

Hepatic involvement in sarcoidosis might be a perplexing diagnostic problem.

The decisive CT finding with respect to the differential diagnosis was the absence of a mass
effect and intact vascular architecture around the lesions.
In addition, bilateral hilar and mediastinal lymphadenopathy is most commonly identified by a
chest x-ray or CT.

QUESTIONS:

- QUESTIONS:
- What did we originally suspect the patient had? (pancytopenia?)
- Clinical course from perspective of resident? (vs GI consult only)
- Treatment after? (for Pneumonia, liver granulomas)
- Was Ascites Transudative vs Exudative?
- Symptoms before: (abdominal pain) before January 21st?/ Lung symptoms?
- For CT abdomen & pelvis 10/3/2017 what’s the liver finding?
-
- Physical exam correct? (bc has complaint of abdominal discomfort, had fatigue, Dyspnea)
- Does he have productive cough? (yes right bc of sputum gram stain/culture)
- Physical exam for pneumonia/consolidation??
- (Med started? To treat pneumonia)
- Meds to treat Sarcoidosis of liver (Steroid?)
- Resolution?
-
-

He is being managed for possible CAP now by ID and PCP. I am asked to evaluate for abdominal pain.
Prior serologic liver w/up and cardiac w/up was nondiagnostic. .

Low SAAG, High total protein

Abdominal distention (low protein ascites)….

No acute intra-abdominal or intrapelvic CT findings