An unusual case of disseminated sarcoidosis with prominent gastrointestinal symptoms

History and admission findings: A 63-year-old man had for 10 months suffere d from marked weight loss, night sweats, diffuse abdominal pain and incrase d stool frequency. He was admitted to evaluate an ultrasonically abnormal f ocus in the liver parenchyma and elevated liver function parameters. His sc lerae were obviously icteric and he looked under-weight. Investigations: He had a hypochromic microcytic anemia and abnormal liver a nd pancreatic function tests: total bilirubin 3.11 mg/dl, direct bilirubin 2.21 mg/dl, GOT 21 U/l, gamma-CT 422 U/l, alkaline phosphatase 1449 U/l, al pha-amylase 481 U/l, lipase 2827 U/l. The serum creatinine level was elevat ed to 1.47 mg/dl. Computed tomography revealed enlarged liver and spleen as well as an enlargement of intraabdominal lymph nodes, chest radiogram and endoscopic cholangio-pancreatography were unremarkable. Biopsies from the l ower duodenum, large intestine, bone marrow and liver showed inflammatory c hanges with Langhans-type mononuclear granulomas. Together with these findi ngs an increased activity of the angiotensin-converting-enzyme (ACE) indica ted sarcoidosis, other causes having been excluded. Treatment and course: All signs and symptoms rapidly improved under prednis olone, and 4 weeks after begin of treatment the biochemical abnormalities h ad clearly regressed. The raised serum levels of soluble IL-2 receptors and of neopterin, measures of sarcoidosis activity, had decreased. Activity of ACE had fallen. Conclusion: Sarcoidosis can present with diverse clinical signs and symptom s. In a case of multi-system disease that cannot be readily classified, sar coidosis should be included in the differential diagnosis.