[Budd-Chiari syndrome: a rare complication of hepatic sarcoidosis (about one case)]

Current concepts on pathogenesis, diagnosis and management of hepatic sarcoidosis

Sarcoidosis is an inflammatory multisystemic granulomatosis of unknown cause, with a wide range of clinical features, characterized by the presence of non-caseating granulomas. Liver is the third involved organ after lungs and lymph nodes, with a reported prevalence of hepatic involvement in 5 to 25% of systemic symptomatic sarcoidosis. The immunopathogenesis of sarcoidosis is still unknown but it seems to involve the innate and adaptive immune actors in response to a putative antigen in genetically predisposed individuals. Because of its paucisymptomatic presentation, hepatic sarcoidosis may be underdiagnosed. Unspecified impaired general condition, fever, abdominal pain, and jaundice are the main symptoms associated with liver sarcoidosis. Frequently, laboratory liver tests are abnormal. Imaging tools may reveal liver nodular enlargement but can be totally normal. Liver biopsy is often required to confirm the diagnosis. A meticulous workup is mandatory to rule out differential diagnosis of hepatic granuloma. Portal hypertension and liver cirrhosis are the most prevalent complications of hepatic sarcoidosis. Treatment is not necessary in all cases and first line treatment in symptomatic patients requires corticosteroids and/or ursodeoxycholic acid. Immunosuppressants and biologics could be used as second line agents. In severe cases, liver transplantation is indicated.

Hepatic sarcoidosis resembling primary sclerosing cholangitis

We report the case of a 29-year-old man who presented with progressive weight loss, night sweats, abdominal pain and pruritus who was found to have obstructive jaundice and cholestatic pattern of liver injury on laboratory workup. Though findings on magnetic resonance cholangiopancreatography were initially concerning primary sclerosing cholangitis, he was ultimately diagnosed with biliary sarcoidosis after a liver biopsy. This case brings attention to the rare phenomenon of hepatic sarcoidosis causing hyperbilirubinemia and highlights the importance of reaching the correct diagnosis early, as the patient’s symptoms improved after initiation of steroids.

Budd-Chiari Syndrome in a Patient With Simultaneous Diagnosis of Hepatic Sarcoidosis and Nodular Regenerative Hyperplasia

Budd-Chiari syndrome (BCS) is a rare vascular disorder characterized by an obstruction of the hepatic venous outflow. Nodular regenerative hyperplasia (NRH) may develop as a result of an underlying autoimmune disease such as hepatic sarcoidosis. Only a few case reports have described cases with either NRH or hepatic sarcoidosis associated with BCS. We present a 42-year-old man presenting with BCS and signs of portal hypertension who was found to have an underlying pathological diagnosis of both hepatic sarcoidosis and NRH and who was successfully treated with a transjugular intrahepatic portosystemic shunt.