Can a rheumatologic condition, such as sarcoidosis, be the underlying cause of steatohepatitis, seizures, and eczema?

Sarcoidosis as a Unifying Rheumatologic Diagnosis

Yes, sarcoidosis is a rheumatologic condition that can explain all three manifestations in this patient—steatohepatitis, seizures, and eczema-like skin lesions—and should be strongly considered as the unifying diagnosis. 1, 2

Why Sarcoidosis Fits This Clinical Picture

Sarcoidosis is a multisystem granulomatous disease that can affect virtually any organ system, making it capable of producing this exact constellation of symptoms. 1, 3

Hepatic Involvement (Steatohepatitis)

• The liver is the third most commonly affected organ in sarcoidosis after the lungs and lymph nodes, though most patients with hepatic sarcoidosis are asymptomatic or have mild presentations. 4
• Hepatic sarcoidosis can present with elevated alkaline phosphatase (greater than three times the upper limit of normal is considered a probable feature), hepatomegaly, and imaging showing enlargement or nodules in the liver. 1
• The granulomatous infiltration can mimic or coexist with steatohepatitis on imaging and clinical presentation. 4

Neurologic Involvement (Seizures)

• Neurosarcoidosis occurs in approximately 5-15% of sarcoidosis patients and can present with seizures due to parenchymal brain involvement or leptomeningeal disease. 5
• Gadolinium enhancement on MRI of the CNS is a highly probable imaging feature supporting sarcoidosis diagnosis. 1
• Seizures can result from granulomatous inflammation affecting the brain parenchyma, and this represents a serious manifestation requiring aggressive treatment. 5

Skin Involvement (Eczema-like Lesions)

• Maculopapular, erythematous, or violaceous skin lesions are probable features of sarcoidosis, and subcutaneous nodules are also common. 1
• While the patient describes "eczema," sarcoid skin lesions can be mischaracterized as eczematous when they are actually granulomatous infiltrates. 2
• Lupus pernio (highly probable feature) and erythema nodosum are classic cutaneous manifestations, but sarcoidosis can present with various skin findings. 1

Diagnostic Approach

Initial Evaluation

• Obtain chest imaging (CT scan) immediately to look for bilateral hilar adenopathy and perilymphatic nodules, which are highly probable features even in extrapulmonary disease. 1, 2, 5
• Check serum ACE level (elevated above 50% of the upper limit of normal is considered abnormal), serum calcium, alkaline phosphatase, and complete blood count. 1, 2
• Perform gadolinium-enhanced MRI of the brain to evaluate for leptomeningeal enhancement, parenchymal lesions, or cranial nerve involvement. 5

Tissue Confirmation

• Biopsy the most accessible affected organ (skin lesions if accessible, or liver if hepatic involvement is prominent) to demonstrate noncaseating granulomas. 1, 2, 5
• The diagnosis requires three criteria: compatible clinical presentation, noncaseating granulomatous inflammation on tissue, and exclusion of alternative causes (infections, malignancy, other granulomatous diseases). 1, 2

Critical Exclusions

• Rule out tuberculosis, fungal infections, and malignancy as these can mimic sarcoidosis and represent the most common causes of misdiagnosis. 1, 5
• Consider chronic beryllium disease if there is occupational exposure (blood lymphocyte proliferation test is diagnostic). 1
• Exclude granulomatosis with polyangiitis and other vasculitides with ANCA testing if clinically indicated. 1

Important Caveats

Cardiac Screening is Mandatory

• Even without cardiac symptoms, evaluate for cardiac sarcoidosis as it carries significant mortality risk from sudden cardiac death or heart failure. 1, 2, 5
• Obtain baseline ECG and consider cardiac MRI if any abnormalities are detected or if there are conduction abnormalities. 2, 5

Demographic Considerations

• While sarcoidosis is more common in African Americans and Scandinavians, it occurs across all ethnic groups including Indians. 2, 3
• The age of 39 years fits the typical presentation (most common in adults under 50 years). 3

Treatment Implications

• Corticosteroids are the mainstay of treatment for symptomatic sarcoidosis, particularly with neurologic and hepatic involvement. 1, 5, 4
• Neurosarcoidosis with seizures requires aggressive treatment with high-dose corticosteroids, and steroid-sparing agents like methotrexate are frequently needed. 5
• TNF inhibitors (infliximab, adalimumab) are effective for refractory cases. 1, 5

Monitoring Strategy

• Follow liver function tests, complete blood count, and serum calcium every 6-12 months. 1, 2
• Monitor for treatment response and disease progression with serial imaging. 2