A 76-year-old female with past medical history of Paroxysmal Atrial Fibrillation, HTN, CAD, and cholangiocarcinoma (in remission since 2002) presented after a mechanical fall and also complained of increasing abdominal distention.
Initial labs revealed pancytopenia, hypercalcemia, and an elevated alkaline phosphatase level. A 1,25 vitamin D level was elevated with a low PTH level and a negative PTH related peptide. Abdominal ultrasound demonstrated ascites and splenomegaly. CT of the chest showed a chronic, loculated left pleural effusion and mildly enlarged mediastinal lymph nodes. Further labs revealed an elevated Angiotensin converting enzyme level.
The hospital course was significant for a thoracentesis and paracentesis, both negative for malignant cells and transudative in nature. An echocardiogram displayed no evidence of heart failure. CT of the abdomen with contrast revealed a normal appearing liver, with intraperitoneal varices consistent with portal HTN. A liver biopsy revealed advanced stage sarcoidosis with early cirrhosis. A bone marrow biopsy to evaluate for malignancy demonstrated numerous noncaseating granulomas consistent with sarcoidosis.
The patient clinically improved with oral steroids and was subsequently discharged home.
Sarcoidosis is a granulomatous disorder which can affect every organ system. It typically presents with bilateral hilar adenopathy, pulmonary reticular opacities, fatigue, and weight loss. Up to 30% of patients present with extrapulmonary sarcoid, with the most common sites of disease being the skin, eyes, heart and central nervous system.
While the liver is involved in the majority of patients, symptomatic hepatic sarcoidosis only occurs in 5 to 15 percent of cases. Splenomegaly occurs in about 20% of patients and can lead to leukopenia, anemia, and thrombocytopenia, however pancytopenia is rare. In our case, pancytopenia was due to direct bone marrow involvement.
Ascites in sarcoidosis is rare. When it does occur, it is usually transudative secondary to right heart failure or secondary to portal HTN from biliary cirrhosis, not liver cirrhosis as in this case. There have also been case reports of exudative ascites secondary to peritoneal sarcoidosis.
ACE levels are elevated in 30-90% of patients with sarcoidosis, and 1,25 vitamin D levels can also be elevated as they were in this case. The confirmatory diagnosis is histopathology demonstrating noncaseating granulomas.
Sarcoidosis is a disorder commonly encountered by hospitalists and it often has a multisystem clinical presentation. This case was unique in that it showed a very atypical presentation of ascites, hypercalcemia, and pancytopenia, initially thought to be due to an underlying malignancy, and ultimately attributed to sarcoidosis. This case highlights the importance of understanding and recognizing the various clinical manifestations of sarcoidosis for hospitalists.
To cite this abstract:Navetta B, Feldhamer K. Sarcoidosis: The Other Great Mimicker. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 631. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/sarcoidosis-the-other-great-mimicker/. Accessed July 20, 2019.