Case Presentation:
We report an unusual case of a Pakistani housewife admitted for refractory ascites, fever, weight loss, and fatigue and found to have granulomatous hepatitis secondary to sarcoidosis. A 36‐year‐old woman was admitted to our hospital in March 2009 with a chief complaint of fever, abdominal distension, and weakness. Since April 2007 she has had a history of recurrent fevers, night sweats, and weight loss despite having a good appetite. She was admitted to multiple hospitals for the past 2 years. Initial PET scan notable for tracer uptake in an enlarged spleen. Percutaneous spleen biopsy in August 2008 revealed granulomatous inflammation. She was treated empirically with conventional antibiolics at that time, but her constitutional symptoms persisted. Later, a percutaneous liver biopsy revealed granulomatous inflammation with some central necrosis and areas of fibrosis. An extensive infectious disease workup was unrevealing in 2008. She was noted to be PPD negative in December 2008. At our hospital, paracentesis showed 539 WBCs, 70% mononuclear cells. Acid‐fast bacterial cultures were positive for Mycobacterium abscessus. We started her on moxifloxacin and clarithromycin for atypical mycobacterial infection. Subsequent paracentesis samples were negative for growth. Her workup was negative for hemochromatosis, Wilson s disease and autoimmune hepatitis, HIV, and hepatitis B and C. Her upper endoscopy was positive for mild gastritis. A reconsideration of her case concluded that the atypical mycobacterium was likely a contaminant and that the major process on liver biopsy was sarcoidosis. A repeat transjugular liver biopsy showed rare granulomata with bridging fibrosis. She continued to have impressive ascites. She received 2‐3 weeks of atypical mycobacterial coverage. Her transjugular pressure measurements were compatible with Budd‐Chiari syndrome. Given her continued problems with impressive ascites, she had a transjugular intrahepatic portosystemic stent/shunt (TIPS) placemenl in June 2009, and since then she has not had any further ascites. She was started on prednisone for sarcoidosis in April 2009. She was followed up in September 2009 and has not had any levers nor weight loss since April 2009.
Discussion:
Evidence‐based medicine supports the use of prednisone for preventing onset of cirrhosis in patients with hepatic sarcoidosis, but our patient already had significant fibrosis on liver biopsy. Prednisone was started with the intention of preserving the remaining liver function in our patient. She became asymptomatic with prednisone. Her ascites completely resolved after TIPS.
Conclusions:
Our case is a rare presentation of sarcoidosis as ascites. Since our patient was from Asia, Mycobacterium tuberculosis was high in the differential when her clinical presentation was constitutional symploms and ascites. She was empirically treated with antibiotics and repeated paracentesis for The past 2 years. Transjugular pressure measurements and liver biopsy helped us to solve her case.
Author Disclosure:
K. Prakasa, none; P. Ranasinghe, none.