A Challenging Case of a Patient Presenting With Ascites Diagnosed Later As Systemic Sarcoidosis: A Patient Journey Over a Decade

Sarcoidosis is a multi-system granulomatous disease that can affect almost any organ. While pulmonary involvement is common, abdominal sarcoidosis is uncommon and can mimic infections or malignancy. Distinguishing sarcoidosis from abdominal tuberculosis is particularly challenging in patients from endemic regions. We report a diagnostically complex case of a 38-year-old woman of Bangladeshi origin who initially presented with respiratory and systemic symptoms in 2010. Over more than a decade, she exhibited a broad spectrum of clinical manifestations including bilateral sensorineural hearing loss, chronic anterior uveitis, parotid gland swelling, ascites, omental caking, and abdominal lymphadenopathy. Despite multiple inconclusive investigations and empirical anti-tuberculosis treatments, the final diagnosis of systemic sarcoidosis with abdominal involvement was confirmed via omental biopsy and steroid responsiveness in late 2023. The patient continues on maintenance steroids with no further flare-ups or side effects. This case highlights that sarcoidosis may present atypically, including with predominant abdominal involvement, and should be considered in patients with chronic multi-system inflammatory disease. The presence of non-caseating granulomas in the context of negative tuberculosis investigations should prompt consideration of sarcoidosis. Misdiagnosis may result in inappropriate treatment and significant delays in care. A favourable response to corticosteroid therapy can support the diagnosis in cases of diagnostic uncertainty. Long-term follow-up remains essential given the relapsing-remitting nature of the disease.