Granulomatous disease of the liver, spleen, lymph nodes and spine

Case contributed by Jayanth Keshavamurthy

Presentation

Presenting with 11 kg weight loss. Bloods: elevated GGT and alkaline phosphatase. He is not an alcoholic.

Patient Data

Age: 55 years
Gender: Male

No major abnormality seen on ultrasound.

Gastroenterologist was concerned for cholestasis given elevated alkaline phosphatase.

On the MRI the spine lesions were picked up easily but not the liver and spleen lesions, but these can be seen better on the CT images.

Multiple sub-5 mm low density lesions are seen in the liver and spleen. These lesions were difficult to discern on MRI, but are seen retrospectively.

Enlarged mediastinal lymph nodes seen and no evidence of lung involvement by sarcoidosis.

Sclerotic bone lesions seen corresponding to the MRI findings.

Case Discussion

Presenting complaint of weight loss with elevated GGT and alkaline phosphatase in a male patient without history of alcoholism.

Fractionation of alkaline phosphatase performed. Hepatitis viral serology negative.

Antimitochondrial antibody was negative and so primary biliary cirrhosis less likely.

Liver biopsy and biopsy of mediastinal lymph nodes was performed by gastroenterology which showed non-caseating granulomas in both areas.

Currently he is waiting to be seen by a sarcoid specialist to decide treatment with steroids as this is most likely a non-pulmonary acute manifestation of sarcoidosis.

This case again highlights the role of multiple modalities in making the correct diagnosis despite CT coming out ahead as it is less operator dependent and requires less patient cooperation for breath holding.

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