P Wong¹, V Bain²

Divisions of Gastroenterology, ¹McGill University, Montreal, Quebec, Canada, and ²University of Alberta, Edmonton, Alberta

Hepatic granulomas have been reported in up to 10% of needle liver biopsy specimens and may indicate an underlying systemic process.  The differential for granulomatous liver disease is extensive and includes infections, sarcoidosis, drug and foreign body hypersensitivity reactions, autoimmune diseases and malignancy.

A 56 year old man was found to have persistently elevated liver enzymes in his workup for fatigue, lethargy and a 24 lb weight loss over 6 months.  A percutaneous liver biopsy demonstrated multiple granulomas and he was referred to the University of Alberta Liver Clinic.  Screening serologies sent before his clinic visit returned positive for histoplasmosis and he was started on itraconazole treatment.  Unfortunately, he returned to hospital that night with coffee ground vomiting and in Addisonian Crisis requiring parenteral steroids and ICU support.  An abdominal CT scan revealed bilaterally enlarged, non-enhancing adrenal glands suggestive of adrenal infarcts secondary to histoplasmosis.  Treatment was initiated with Amphotericin B and a gastroscopy revealed erosive esophagitis as the source of his coffee ground emesis.  Despite complications of renal failure, pneumonia and congestive heart failure, he recovered with medical therapy and was discharged home to complete a prolonged course of itraconazole therapy.

While hepatic granulomas often reflect an occult disease process, the etiology may remain undiscovered in 30-50% of cases despite exhaustive investigations.  An overview of the literature and discussion of the most frequent etiologies is presented.

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