Answer to Photo Quiz: Things are not always what they seem (other causes of hepato-splenic nodules)

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DIAGNOSIS

The final clinical diagnosis was hepato-splenic sarcoidosis (extrapulmonary disease). Because of the elevated liver transaminases, oral corticosteroid treatment was initiated at a dose of 0.5-1 mg/kg/day, with good tolerance and clinical evolution in the patient.
Sarcoidosis is a multisystem granulomatous disease of unknown aetiology, where diagnosed patients have pulmonary involvement in almost 90% of the cases.¹ Extrapulmonary involvement is common and all organs may be affected (especially the lymph nodes, eyes, joints, central nervous system), but it is rare to find isolated extrapulmonary disease (less than 10% of the patients).² Without any symptoms, it is even more difficult to make the diagnosis. The isolated splenic or hepatosplenic involvement is uncommon, and these patients may not have any symptoms at all. In this situation it may be necessary to use multiple tests because there may be added difficulty in differentiating the lesions of other diseases such as lymphoma or metastasis³ , or even reach splenectomy.⁴


REFERENCES

1. Lannuzzi MC, Rybicki BA, Teirstein AS. Sarcoidosis. N Engl J Med. 2007;357: 2153-65. 
2. Vardhanabhuti V, Venkatanarasimha N, Bhatnagar G, et al. Extra-pulmonary manifestations of sarcoidosis. Clin Radiol. 2012;67:263-76. 
3. Agrawal K, Chawla YK, Bhattacharya A, Mittal BR. Fluorodeoxyglucose positron emission tomography / computed tomography findings in nodular hepatic and splenic sarcoidosis. World J Nucl Med. 2014;13:144-5. 
4. Raber EL, Bean J, Beck P. Splenic sarcoidosis: a case report and review of the imaging findings of multiple incidental splenic lesions as the initial presentation of sarcoidosis. Can J Gastroenterol. 2011;25:477-8.