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Year : 2017  |  Volume : 60  |  Issue : 4  |  Page : 608-609
Hepatic, splenic and thyroidal nodular sarcoidosis

Department of Pathology (Cardiovascular and Thoracic Division), Seth GS Medical College, Mumbai, Maharashtra, India

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Date of Web Publication12-Jan-2018

How to cite this article:
Wadhwa P, Vaideeswar P. Hepatic, splenic and thyroidal nodular sarcoidosis. Indian J Pathol Microbiol 2017;60:608-9

How to cite this URL:
Wadhwa P, Vaideeswar P. Hepatic, splenic and thyroidal nodular sarcoidosis. Indian J Pathol Microbiol [serial online] 2017 [cited 2022 May 23];60:608-9. Available from: https://www.ijpmonline.org/text.asp?2017/60/4/608/222963

   Case Report Top

A 62-year-old woman was brought to the Emergency Services Department at our tertiary-care center in an unconscious state. She had been on a liquid diet for the past three months due to abdominal discomfort and episodic dull-aching pain, especially after intake of food. There had also been a loss of weight and appetite. The only investigation available was an abdominal ultrasonography performed a month back, which had suggested splenic abscesses. She expired within 20 minutes of admission. A medico-legal autopsy was performed. The cause of death was due to critical stenosis of the left anterior descending coronary artery. Interesting features were seen in the spleen, liver, thyroid and lungs. The spleen (160 gm) showed well-spaced out, discrete, large yellowish-brown nodules (about 15 in number) that ranged in sizes from 1 to 2 cm [Figure 1]a and [Figure 1]b. The liver weighed 1.2 kg. The capsular and the cut surfaces [Figure 1]c showed multiple glistening grey-white to pale yellow nodules, measuring 0.2 to 0.5 cm in size, resembling mixed nodular cirrhosis. The nodules in both these organs showed confluent non-caseating granulomas composed of a core of epithelioid cells and multinucleated giant cells with a prominent fibrous cuff infiltrated by lymphocytes [Figure 2]a and [Figure 2]b. Foci of necroses, caseous or otherwise were not seen in these granulomas. Special stains for mycobacteria and fungi were negative. The lymph nodes at the splenic and hepatic hila, and in the perigastric region also showed such granulomas. In addition, the entire thyroid gland was diffusely enlarged with a grey-white lobulated cut surface along with few small firm nodules [Figure 1]d; the histology revealed synchronous sarcoid granulomas [Figure 2]c and auto-immune thyroiditis [Figure 2]d. The lungs were subcrepitant with a granular feel; speckled white areas around the broncho-vascular bundles were seen on the cut surface. The histology from these areas showed lymphangitic pattern of distribution of these granulomas on histology. A diagnosis of an “incidental” systemic sarcoidosis was made.
Figure 1: (a) Capsular surface of the spleen showing presence of nodules, some which show central umbilication (arrow); (b) cut surface of the spleen with circumscribed pale brownish-yellow nodules; (c) liver slice showing fine nodularity; (d) serial slices of the enlarged thyroid showing lobulated whitish cut surface with few nodules

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Figure 2: Compact nonnecrotizing granulomas in (a) spleen (H and E, ×250), (b) liver (H and E, ×250) and (c) thyroid (H and E, ×400); (d) thyroid follicles lined by oncocytic cells (H and E, ×400)

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   Discussion Top

Sarcoidosis is a systemic granulomatous disease of unknown etiology, related probably to, exposure to one or more exogenous antigens, superimposed on a background of genetic susceptibility. It usually presents in adults, especially women under 40 years of age, affecting the lungs in more than 90% of patients.[1] The progression of sarcoidosis falls into five stages: Stage 0 – no lympadenopathy or pulmonary infiltrates; Stage 1 – Hilar and mediastinal adenopathy alone; Stage 2 – Adenopathy and pulmonary infiltrates; Stage 3 – Pulmonary infiltrates alone and Stage 4 – Pulmonary fibrosis.[1] Such an involvement leads to non-specific respiratory symptoms with associated constitutional symptoms. The exact incidence of sarcoidosis in India is not known, but its detection and documentation has been on the ascent, attributable to both increased awareness and increased incidence.[2] Our patient had pulmonary granulomas in a characteristic lymphangiitic pattern (clinically stage 3), but did not have respiratory complaints, a scenario seen in up to 60% of patients.[1] She strikingly had predominant hepato-splenic (which had lead to her initial symptoms) and thyroidal involvement.

Infiltration of liver and spleen are common in systemic sarcoidosis, manifesting as homogenous organomegaly clinically and radiologically; majority of such patients are asymptomatic. In the present case, there were grossly visible nodules in the liver and spleen. This has an incidence of about 5% to 15% and can simulate hepatic cirrhosis/nodular regenerative hyperplasia and splenic lymphoma, respectively.[3],[4] Though this patient had only abdominal discomfort, such hepato-splenic nodules can lead to severe clinical presentation such as cholestatic jaundice, portal hypertension, moderate to marked splenomegaly with hypersplensim.[3],[4] The other surprising finding was involvement of the thyroid. Although autoimmune thyroid diseases are known to be associated with sarcoidosis, co-existence of both diseases within the thyroid is distinctly unusual.[5]

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Conflicts of interest

There are no conflicts of interest.

   References Top

Baughman RP, Culver DA, Judson MA. A concise review of pulmonary sarcoidosis. Am J Respir Crit Care 2011;183:573-81.  Back to cited text no. 1
Sharma SK, Mohan A. Sarcoidosis: Global scenario and Indian perspective. Indian J Med Res 2002;116:221-47.  Back to cited text no. 2
Dourakis SP, Cokkinos DD, Soultati AS, Alexopoulos A, Nezi V, Archimandritis AJ. A case of liver sarcoidosis mimicking cirrhosis. Clin Imaging 2007;31:47-9.  Back to cited text no. 3
Bauones S, Le Corroller T, Durieux O, Guenoun D, Del Grande J, Pirro N, et al. Splenic sarcoidosis mimicking neoplastic disease. J Clin Ultrasound 2014;42:38-41.  Back to cited text no. 4
Sasaki H, Harada T, Eimoto T, Matsuoka Y, Okumura M. Concomitant association of thyroid sarcoidosis and Hashimoto's thyroiditis. Am J Med Sci 1987;294:441-3.  Back to cited text no. 5

Correspondence Address:
Pradeep Vaideeswar
Department of Pathology (Cardiovascular and Thoracic Division), Seth GS Medical College, Parel, Mumbai - 400 012, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPM.IJPM_242_17

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