Praneeth Bandaru, MD1, Manan Jhaveri, MD2, Febin John, MD2, Denzil Etienne, MD2; 1The Brooklyn Hospital Center, Brooklyn, NY; 2Brooklyn Hospital Center, Brooklyn, NY
Introduction: Sarcoidosis is an immune mediated multisystem chronic granulomatous disease that affects almost every tissue in the body. Involvement of the gastrointestinal(GI)tract is rare and seen in about 5-10% of the patients with sarcoidosis. The stomach is the most common site in the GIT. We report a case of diffuse GI tract involvement which is rarely reported in literature.
Methods: A 47-year-old African American man with history of pulmonary and lymphatic sarcoidosis (not on treatment) was evaluated for chronic abdominal pain and watery diarrhea with 25 pounds weight loss in the last 6 months. Physical exam was significant for mild diffuse abdominal tenderness. Extensive stool workup, autoimmune workup including ANA, ASCA, ANCA and Quantiferon gold were negative. ACE levels were normal. Recent CT scan of the abdomen that was performed 3 months prior to presentation showed wall thickening of multiple loops of small bowel and retroperitoneal lymph nodes >1cm [Figure-1]. Colonoscopy showed diffuse moderate inflammation extending from sigmoid colon to Ileocecal valve [Figure-2]. Random biopsies from colon and terminal ileum showed non-caseous granuloma formation and villous flattening [figure 3]. He was diagnosed with GI sarcoidosis after infectious and other autoimmune causes of granulomatous disease were excluded. He is planned to start oral steroids given his symptoms and systemic involvement. Discussion: Sarcoidosis of the GI tract can occur in patients with known disease as well as patients who have no history of the diagnosis. It is more frequent in African- Americans and has a predilection towards young women. Clinically symptomatic disease occurs in less than 1% of patients. According to the area of GI tract involvement, symptoms can include GERD, abdominal pain, gastroparesis, chronic diarrhea, weight loss, gastrointestinal hemorrhage, stricture or obstruction. Cross sectional imaging and endoscopic findings are nonspecific and can overlap with other diseases. The characteristic histologic presence of non-caseating granulomas in the absence of other autoimmune, infectious, malignant causes confirms the diagnosis. Asymptomatic or mild symptoms do not need treatment. Immunosuppressants are required if significant symptoms and complications occur. Surgical intervention is required for management of stricture, intestinal obstruction and intussusception. ACE levels are helpful to check for response to therapy, relapse, and disease course.
Figure 1: A- Frontal view of CT abdomen showing thickened loops of small bowel in left upper quadrant. B- Axial views of CT abdomen showing a 2.8 x 1.3 cm enlarged lymph node and splenomegaly.
Figure 2: A, B, C: Colonoscopy views showing diffuse moderate inflammation characterized by congestion (edema), erythema, friability, granularity, and nodularity/pseudo polyps in entire colon extending from sigmoid colon to Ileocecal valve
A: Terminal ileum biopsy- H&E stain, 40X showing small bowel mucosa with mild active chronic ileitis, flattened villous pattern and noncaseating microgranuloma formation.
B: Immunohistochemical stain with CD68 reveal scattered and few small clusters of histiocytes.
Disclosures: Praneeth Bandaru indicated no relevant financial relationships. Manan Jhaveri indicated no relevant financial relationships. Febin John indicated no relevant financial relationships. Denzil Etienne indicated no relevant financial relationships.