Unusual Small Bowel Stricture Caused by Gastrointestinal Sarcoidosis

Introduction: Sarcoidosis is a multisystem disorder that can affect practically any organ in the body. Gastrointestinal involvement especially, intestinal sarcoidosis is exceedingly rare. Case Description/Methods: 29-year-old African-Caribbean male was admitted to the hospital with progressively worsening right sided flank pain over one year. This was associated with intermittent episodes of vomiting, loss of appetite, and 20lb unintentional weight loss. He denied diarrhea, hematochezia, did not take any medications and no prior exposure to tuberculosis. Physical exam was unremarkable except for mild tenderness to palpation in right side peri-umbilical area without guarding or rebound. Laboratory studies showed, WBC: 6.0 K/uL, Hb:11. 6g/dL, platelets 510 K/ul, elevated erythrocyte sedimentation rate >130 mm/hr and C-reactive protein 69 mg/L. QuantiFERON gold test was negative. Computerized tomography of the abdomen and pelvis showed dilated proximal small bowel loops along with a stricture in the mid-jejunum and mesenteric lymphadenopathy (Figure 1a). The area of stricture could not be reached with a push enteroscopy. Colonoscopy with terminal ileum intubation did not show any abnormalities. Hospital course was complicated by exudative pleural effusion and ascites with negative cytology, but culture was positive for Propionibacterium acne (P. acne). Given unclear etiology of underlying process, a diagnostic laparoscopy was performed with findings concerning for possible peritoneal carcinomatosis (Figure 1b). Biopsy of peritoneum and omentum showed non-caseating granulomas (Figure 1c). Special stains for mycobacteria, T. whipplei, fungal and parasitic infections were negative. After eliminating infectious, autoimmune and malignant causes, a diagnosis of sarcoidosis was made, especially as it has been associated with P. acne. Patient was started on intravenous prednisone and discharged on oral prednisone taper with no resolution of symptoms in follow-up visits. Discussion: Sarcoidosis is a chronic granulomatous disorder of unknown etiology and characterized by the formation of non-necrotizing granulomas. P. acnes is a gram-positive bacterium, associated with development of acne. Interestingly, it is also the only microorganism isolated from sarcoid lesions by bacterial culture and is reported to play an important role in the development of sarcoidosis. Steroids remain the mainstay of therapy in symptomatic patients.Figure 1.: A: Computerized tomography of abdomen and pelvis indicated dilated proximal small bowel loops along with a stricture (blue arrow) in the mid-jejunum and mesenteric lymphadenopathy. B: Diagnostic laparoscopy revealed peritoneal carcinomatosis (blue arrow) C: Biopsy of peritoneum and omentum showed non-caseating granulomas (blue arrow).