Hepatic granulomatosis and sarcoidosis. Further observations

The etiology of hepatic granulomatosis discovered in patients with normal chest roentgenograms is controversial. Among 18 such patients studied in recent years, sarcoidosis was identified as the cause in 15 by demonstration of granulomatous inflammation in extrahepatic tissues, employing a variety of biopsy methods. Serum angiotensin levels were raised in all 10 patients tested and gallium scans were helpful in four of six cases. Prolonged fever was the most common symptom, but three patients had severe right upper quadrant pain, a manifestation of hepatic sarcoidosis not previously described. Improvement on corticosteroids was observed in the 14 treated patients, but incomplete response led to use of cytotoxic drugs in three cases. Sarcoidosis presents with normal chest roentgenograms more often than is appreciated and appears to be a common cause of unexplained persistent hepatic granulomatosis. A firm diagnosis should be established since treatment is long and frustrating. The prognosis is good but treatment for years is required in most cases.