Sarcoidosis is a multisystem inflammatory disorder of unknown etiology. It shows a great variety of clinical presentation, organ involvement, and disease progression. Lungs and lymphoid system are the most common sites involved with a frequency of 90% and 30%, respectively. Extrapulmonary involvement of sarcoidosis is reported in 30% of patients and abdomen is the most frequent site. Furthermore, peritoneal involvement is extremely rare in sarcoidosis. The case presented here described peritoneal manifestations of sarcoidosis without involvement of lungs. A 78-year-old woman possessing signs of malignancy on blood test and abdominal magnetic resonance imaging underwent laparatomy with a suspicion of ovarian malignancy. The macroscopic interpretation during surgery was peritoneal carcinomatosis. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritoneal biopsies, total omentectomy, and appendectomy were performed. Final histopathological result revealed the diagnosis of sarcoidosis. Clinicians must keep in mind that peritoneal sarcoidosis can mimic intra-abdominal malignancies.
Sarcoidosis is a multisystem inflammatory disorder of unknown etiology. The cause may be related to a bacterial or fungal infection or an immune response from an unidentified antigen [
A 78-year-old woman, gravida 4, para 3, presented with complaints of dyspnea, abdominal discomfort, and distension that persisted for one month on December 2014. Her medical history revealed no history of tuberculosis and of asbestos exposure. On abdominal examination, she had abdominal tenderness without rebound or defense signs. Hepatosplenomegaly and lymphadenopathy were not noted on physical examination. Chest examination was dull to percussion over both hemithorax and respiratory sounds diminished at both basal regions. Although blood tests were at normal range, serum CA 125 and CA 15.3 levels were 116 u/mL and 49,1 u/mL, respectively. Ultrasonography of the abdomen confirmed the presence of diffuse ascites. Chest radiography revealed bilateral pleural effusion. Thickening of parietal peritoneum and nodular implantation at right side of lower abdomen and sign of omental cake were detected on T1-weighted fat-saturated, contrast-enhanced transverse images of abdominal magnetic resonance (MR) (Figure
An explorative laparotomy procedure was planned with the preliminary diagnosis of intraabdominal malignancy. At laparotomy under spinal anesthesia, miliary white nodules measured 2–5 mm in diameter studded the diaphragm, liver, omentum, gastric serosa, small and large intestines, whole surface of parietal peritoneum, and both ovaries. Furthermore, approximately 1,5 liters of nonbloody ascites was aspirated from intraabdominal cavity. The sample of ascites was sent for cytological examination. Omental cake appearance was prominent. Interpretation of case was manifestation of peritoneal carcinomatosis. Cytological examination and frozen section pathology resulted in the fact that malignancy could not be excluded. Then we performed total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritoneal biopsies, total omentectomy, and appendectomy. Numerous lymphadenopathies of bilateral iliac, obturator, and paraaortic sites were noted. The size of lymph nodes ranged from 2,0 cm to 5,5 cm in diameter. Enlarged lymph nodes were sampled during the operation. She was discharged from the hospital after uneventful postoperative course at 10th day.
Final histopathology demonstrated epithelioid noncaseating granulomas containing multinucleated giant cells in the serosal surfaces of uterus, ovaries, fallopian tubes, peritoneum, and omentum as well as iliac, obturator, and paraovarian lymph nodes (Figure
The manifestations of abdominal sarcoidosis are less characteristic. It may mimic neoplastic or infectious diseases such as lymphoma, diffuse metastasis, granulomatous, and mycobacterial infection [
Exudative ascites (bloody and nonbloody) and abdominal pain are the mostly seen clinical presentations. Multiple granulomatous nodules involving peritoneum or a single peritoneal lesion may be seen. Enlarged lymph nodes are detected in nearly 30% of patients, especially in the porta hepatis, para-aortic region, and the celiac axis [
Omental cake is an unfavorable sign and mostly caused malignancy. It is associated with infiltration of the omental fat. The other causes of omental cake are inflammatory conditions such as tuberculosis, Crohn’s disease, phlegmonous pancreatitis, and granulomatous enterocolitis. The differential diagnosis should also be focused on benign tumors derived from lymphatic, vascular, neuromuscular, or fatty tissues [
Homogenous hepatosplenomegaly (HSM) is typically related to extrapulmonary sarcoidosis. In 5 to 15% of cases, multiple, hypoechoic, hypodense, and hypointense nodules are scattered in the liver and spleen. HSM in sarcoidosis is easily misdiagnosed as lymphoma, infection, or metastatic disease [
Sclerosing peritonitis is a syndrome characterized by abdominal pain, intestinal obstruction, and thickening of peritoneum with massive adhesions. This condition is easily curable by steroid therapy. The other causes of sclerosing peritonitis are bacterial infections (mycobacteria), foreign bodies, peritoneal dialysis, asbestos exposure, carcinoid syndrome, or being idiopathic [
Carbohydrate antigen or cancer antigen 125 (CA 125) is a tumor marker secreted by the mesothelial cells lining the peritoneal cavity. It has also been identified on tissues of nonmesothelial origin such as tracheobronchial epithelium, epithelium of pancreas, colon, gallbladder, stomach, kidney and breast, amniotic tissue, placenta, and cervical mucous membrane. Therefore, inflammation of these regions can yield elevated serum levels of CA 125. Elevated CA 125 levels have also been reported in endometriosis, pelvic inflammatory disease, during menstruation and pregnancy, after laparotomy, and in numerous conditions [
Although isolated occurrence of sarcoidosis in the genital system is rare, uterine and ovarian involvement are most common sites relatively. Like uterine sarcoidosis, most of the ovarian ones are reported in the reproductive age period. A few cases of ovarian sarcoidosis in postmenopausal women were reported as in our case presentation [
In conclusion, sarcoidosis should be kept in mind for differential diagnosis of intraabdominal malignancies that can affect female genital organs and peritoneum. Therefore, optimum management of such patients should be delivered and inessential invasive procedures can be avoided.
The authors declare that there is no conflict of interests regarding the publication of this paper.