INTRODUCTION: Sarcoidosis is a systemic granulomatous disease of unknown etiology that typically predominates as a respiratory disease process. Hepatic involvement is uncommon and reported in only 11.5% of cases and even rarer is symptomatic hepatic involvement that occurs in approximately 5 to 30% of those cases. Epidemiological studies show substantial variations in extrapulmonary involvement based on race, with few studies on the Hispanic population. This case report presents a Hispanic female who underwent extensive workup and was diagnosed with symptomatic hepatic sarcoidosis. CASE DESCRIPTION/METHODS: A 27-year-old Hispanic woman with history of a mediastinal mass presented to the emergency department with an abrupt onset of right upper quadrant (RUQ) abdominal pain and nausea. Liver biochemical tests were severely elevated in a hepatocellular pattern. A RUQ ultrasound showed a dilated common bile duct (CBD) with a questionable stone in the CBD. Next, a magnetic resonance cholangiopancreatography was performed and demonstrated a normal CBD without biliary ductal dilatation or choledocholithiasis. Workup for chronic liver disease was negative, as well as extensive workup for other causes (Table 1). Then a liver biopsy was performed with histology demonstrating scattered non-necrotizing granulomas (Figure 1) with negative stains for mycobacterial and fungal organisms. Review of past medical records revealed a biopsy of her mediastinal mass with histology showing a non-necrotizing granulomas (Figure 2). A diagnosis of sarcoidosis was established and she was started on oral prednisone and referred to pulmonology. DISCUSSION: A diagnosis of sarcoidosis involves a suggestive history, granulomas in two organs, negative staining for acid fast bacilli, and a lack of drug-induced disease. The majority of patients with hepatic granulomas have primary biliary cholangitis (PBC). Screening for anti-mitochondrial antibodies and elevated IgM levels is important as these are present in >90% of those with PBC. Infectious diseases should be ruled out including tuberculosis, AIDS-related diseases, Q fever, and Brucellosis. Race is the most important risk factor for developing extrapulmonary sarcoidosis, possibly due to involvement of the reticuloendothelial system. Hispanics account for 18.1% of the U.S population. It is possible that Hispanics are at increased risk for extrapulmonary sarcoidosis compared to whites, but more Hispanic epidemiology studies are warranted.
INTRODUCTION: Melanoma accounts for 5% of all skin cancers, with lentigo maligna melanoma (LMM) accounting for 10–15% of melanomas. The LMM variety harbors a risk of invasive progression up to 20%. Studies have shown that the small bowel is a preferred site for melanoma metastasis due to its high vascularity, and approximately 60% of patients diagnosed with melanoma skin cancer will have gastrointestinal (GI) metastasis. The usual time for primary melanoma to GI metastasis is 60–90 months. Metastatic melanoma is a rare cause of GI bleeding but should be considered in all patients with history of cutaneous melanoma. This case report presents a man with history of LMM who presented with melena and capsule endoscopy identified small bowel metastasis of the primary cutaneous melanoma. CASE DESCRIPTION/METHODS: A 78-year-old man with medical history of cutaneous melanoma and Mohs surgical resection 2 years prior presented to the emergency department for melena over a 2-week duration. One year before this admission the patient presented with similar complaints and esophagogastroduodenoscopy (EGD) with colonoscopy did not yield a bleeding source. At admission he was hemodynamically stable with a hemoglobin of 9.7. Hemoccult testing in the emergency department was negative, but the patient was admitted for monitoring. Gastroenterology was consulted and because the patient had a stable hemoglobin during his stay without hemodynamic compromise, and in-light of recent negative EGD and colonoscopy, the decision was made to follow-up outpatient with capsule endoscopy (CE). On review of CE footage, the patient was found to have an ulcerated mass with active bleeding in the small bowel. Biopsy confirmed the mass was metastatic melanoma. The patient was referred to oncology who found multiple boney and liver metastases and started him on Nivolumab and Zometa. DISCUSSION: Metastatic melanoma spreads to the small bowel in 60% of cases. As in this case, metastatic melanoma to the small bowel can cause an occult GI bleed, or even massive bleeding and hematemesis, with some cases of intussusception also reported. Whatever the presentation, one should have a high index of suspicion of metastasis in patients with a history of cutaneous melanoma and new GI bleeding. Negative EGD and colonoscopy should prompt an investigation with CE to rule out metastatic lesions.
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