S5563 Hidden in the Liver: Hepatic Sarcoidosis Mimicking Mild Liver Dysfunction

Introduction: Hepatic sarcoidosis represents a rare manifestation of sarcoidosis, a chronic multisystem disorder characterized by the presence of non-caseating granulomas within various organs, including the lungs, dermis, spleen, ocular structures, and lymph nodes. This condition frequently presents with nonspecific clinical manifestations or remains clinically silent and may closely resemble alternative hepatic disorders, thus creating a diagnostic dilemma. Case Description/Methods: A 50-year-old man patient presented to the outpatient gastroenterology clinic reporting persistent fatigue accompanied by discomfort localized to the right upper quadrant. The patient denied any history of alcohol use disorder. Detailed clinical, biochemical, radiological, and histopathological assessments were performed to investigate the underlying etiology of the liver dysfunction. The physical examination showed mild hepatomegaly; all other findings were unremarkable. Liver function tests showed a cholestatic pattern with alkaline phosphatase 638 IU/L and gamma-glutamyl transferase 489 IU/L, with normal bilirubin and transaminases levels. The viral hepatitis serologies and the ANA panel yielded negative results. Calcium and angiotensin-converting enzyme (ACE) levels were elevated. Chest and abdomen computed tomography (CT) revealed bilateral hilar lymphadenopathy and hepatosplenomegaly. Liver biopsy was performed and revealed the presence of multiple non-caseating granulomas devoid of any infectious agents. A provisional diagnosis of hepatic sarcoidosis was established. The patient was started on oral prednisolone at a dosage of 40 mg daily, which was subsequently tapered gradually. At follow-up at 4 weeks, the patient reported complete symptom resolution, with liver enzymes returning to normal levels by 8 weeks. Discussion: Hepatic sarcoidosis should be considered in the differential diagnosis of elevated liver enzymes in a cholestatic pattern, particularly in patients with systemic signs of liver dysfunction or lymphadenopathy. Imaging studies may provide suggestive evidence towards the diagnosis; however, liver biopsy remains the definitive method for confirmation. Prompt initiation of corticosteroid therapy can yield remarkable clinical and biochemical improvements, underscoring the necessity for timely identification and intervention.