Gastric Perforation as a Manifestation of Sarcoidosis: A Case Report.

BACKGROUND: Gastrointestinal involvement in sarcoidosis is rare, and clinically apparent disease occurs in fewer than 1% of patients. The stomach is the most frequently affected site, although presentations are usually indolent. Perforation is exceedingly rare, and to our knowledge, this is the first case of gastric perforation attributable to sarcoidosis.

CASE PRESENTATION: A 30-year-old woman presented with 4 months of bilateral lower extremity paresthesia, pleuritic chest pain, progressive dyspnea, abdominal discomfort, and 50 lb unintentional weight loss. Angiotensin-converting enzyme and soluble interleukin-2 receptor were markedly elevated, and autoimmune serologies and extensive infectious workup were negative. Imaging revealed abdominal and pelvic lymphadenopathy, hepatosplenomegaly, and bilateral cavitary pulmonary opacities with mediastinal and hilar lymphadenopathy.During admission, she developed acute abdominal pain with pneumoperitoneum. Emergent laparotomy revealed a 6-mm gastric perforation repaired with a Graham patch, with biopsies revealing lymphohistiocytic aggregates and multinucleated giant cells containing asteroid bodies. Subsequent endobronchial ultrasound-guided mediastinal node biopsy demonstrated granulomatous lymphadenitis, and a bronchoalveolar lavage showed a cD4/CD8 ratio of 15:1, suggesting sarcoidosis. Glucocorticoids were deferred due to surgical repair initially, and hydroxychloroquine was started. Subsequent lung wedge resection confirmed non-necrotizing granulomas. Mycophenolate mofetil was then added and replaced by methotrexate with clinical improvement and resolution of symptoms.

CONCLUSION: Gastric perforation can be a severe complication in sarcoidosis, particularly in patients with multisystemic symptoms that are not otherwise explained. Multidisciplinary involvement is needed to appropriately treat these patients.