Presentation
Presented with significantly elevated liver enzymes and cholesterol levels on routine screening. She denied any abdominal complaints at the time.
Patient Data
1. Multiple non-specific infiltrative lesions throughout the hepatic parenchyma predominantly peripheral in location. These findings are favored to be related to the patient's recent diagnosis of sarcoidosis. An infiltrative malignancy would be in the differential if not for the confirmed biopsy of the lesions.
2. Multiple round low-density lesions throughout the splenic parenchyma that are non-specific and also likely related to the recent diagnosis of sarcoidosis.
3. Obstructing calculus of the proximal left ureter causing mild hydronephrosis.
1. Mediastinal lymphadenopathy with a large supra-aortic lymph node in the upper mediastinum measuring ~2.0 cm in short axis diameter. Additional prominent lymph nodes in the prevascular mediastinum measuring ~1.0 cm. Bilateral hilar adenopathy is also present.
2. 6 mm solid pulmonary nodule in the right upper lobe. Additional nodules in the left upper lobe measuring 4 mm. Additional micronodules in the upper lobes are noted.
Case Discussion
Patient initially presented with elevated liver enzymes and cholesterol levels on routine screening. She denied dyspnea or abdominal pain at this time. Liver ultrasound demonstrated a lobulated isoechoic to slightly hypoechoic left lobar mass deforming the hepatic contour raising concern for cancer with metastasis. An MRI liver with contrast raised concern for cholangiocarcinoma with innumerable liver and splenic metastases. There was also a retroperitoneal lesion concerning for metastasis. US-guided liver biopsy demonstrated the masses to be non-caseating granulomas, as seen in sarcoidosis. A chest CT showed the classic sarcoidosis findings of hilar and mediastinal adenopathy.
Pulmonary manifestations are the commonest in sarcoidosis, typically presenting as bilateral and symmetric hilar lymphadenopathy. Additionally, mediastinal adenopathy, in particular right paratracheal and subaortic nodes, is frequently associated with hilar involvement. This combination of intrathoracic lymphadenopathy is seen as a "lambda sign" on gallium scans. These characteristic findings can also be seen on chest x-ray but CT is much more sensitive and specific for mediastinal lymphadenopathy and associated parenchymal involvement.
Sarcoidosis preferentially affects the upper lobes with granulomas distributed along lymphatic vessels. This causes nodular or irregular thickening of the peribronchovascular interstitium 2. Granulomas can fuse with time, which can mimic metastatic lesions, however, sarcoid nodules have irregular margins and may contain an air bronchogram 1.
CT/MRI of hepatic sarcoidosis may show organomegaly. In addition, less than 15% of patients present with granulomas as multiple hypoattenuating/hypointense nodules 1. Splenic involvement is more common in sarcoidosis than malignancy. On contrast-enhanced CT, splenic nodules are typically hypodense relative to normal spleen 3. Although the GI tract is less commonly affected, when it is, the gastric antrum is the commonest site of disease with imaging findings that vary including ulceration to mucosal thickening and irregularity.
Case contributors:
- Alexander Matyga
- Tejasvini Kapa
- Roger Rozzi, DO
- Sara Hennessy, DO
- Aleksandr Raskind
- Raj Chinnappan, MD
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