A 31-year-old female presented in the emergency room with intermittent epigastric pain for two weeks. The pain was burning in type with no radiation and was worsened by food intake. she also reported nausea usually during the pain but denied any symptoms of vomiting. The rest of the review of the system was negative. She had multiple visits to the emergency room in the last six months for similar complaints. Past medical history was only significant for cholecystectomy for cholelithiasis four years back. Vital signs at presentation were normal, and the rest of the physical examinations were within normal limits except for mild epigastric tenderness without any rebound, guarding or rigidity. Lab tests were significant for normocytic normochromic anemia with hemoglobin of 10.7 g/dL and hematocrit of 33.7%, normal serum lipase of 48 U/L (normal 22-52 U/L). Serum calcium was 8.7 mg/dL (normal 8.9-10.3 mg/dL). The rest of the complete blood count and metabolic panel were normal.
An abdominal sonogram was unremarkable. Computed tomography (CT) scan of the abdomen showed normal abdominal findings with 7 mm pulmonary nodule in the right lower lobe.
A subsequent CT scan of the chest showed multiple bilateral pulmonary nodules with enlarged mediastinal and hilar lymph nodes. After admission, the patient underwent esophagogastroduodenoscopy (EGD) that revealed mild gastritis while antral biopsy showed acute and chronic inflammation with non-caseating granuloma. Subsequent bronchoscopy with transbronchial biopsy showed benign lung tissue with non-necrotizing granuloma.
However, Serum angiotensin-converting enzyme level (ACE) was normal 49 U/L (normal 14-82 U/L). Based on compatible clinical symptoms and histological evidence of non-caseating granuloma; the patient was diagnosed to have active gastric sarcoidosis (Figure 1) with the simultaneous presence of inactive pulmonary sarcoidosis (Figures 2 and 3). Other potential causes of granuloma including Helicobacter pylori, Mycobacterium tuberculosis, fungal organisms, etc. were excluded on histology. Later, she was started on Prednisone 40 mg per day with a progressive resolution of her GI symptoms.
Subsequently, pulmonary function test was also performed during admission which showed normal spirometry compatible with asymptomatic pulmonary sarcoidosis. She was discharged on a tapering dose of prednisone with no recurrence of symptoms at 3 months of follow up.
Computed Tomography (CT) showing hilar lymphadenopathy.