Colonic Sarcoidosis Presenting as Granulomatous Appendicitis.

A 64-year-old woman visited our hospital for diarrhea that had persisted for 6 months. She had been treated for diabetes insipidus for 10 years. Her serum CA 19-9 and CEA level, and fecal tests were normal, and the tuberculin skin test was negative. Computed tomography (CT) (Fig. 1) showed hypertrophy of the colon (white arrows) and appendix walls (red arrow) and enlargement of many lymph nodes in the abdominal cavity (arrow head), but no abnormality in the thoracic region. On the lower intestinal endoscopy, mucosal edema, redness, and erosions were observed in the terminal ileum over the rectum (Fig. 2). Endoscopic biopsy did not permit a diagnosis. Thus, laparoscopic observation was performed and the swelling of the appendix was noticeable. The appendectomy revealed granulomatous appendicitis with many large non-caseating epithelioid granulomas (Fig. 3). These findings led to the diagnosis of colonic sarcoidosis. Diarrhea was resolved in a few days after initiation of prednisolone. Intestinal wall hypertrophy and lymph node enlargement had mostly disappeared on CT one month after treatment initiation and the intestinal mucosa had normalized on the lower intestinal endoscopy. Intestinal sarcoidosis occurs in <1% of sarcoidosis cases [1], and only a few cases have lesions in the large intestine. Symptoms are nonspecific, with endoscopic findings of ulcer and intestinal stenosis [2] and multiple small protruding lesions [3]. Cases without pulmonary lesions account for about 10% of all sarcoidosis cases [4], and this further increased the difficulty of diagnosis. However, other diseases which reveal non-caseating epithelioid granulomas such as tuberculosis and fungal diseases were not identified, and from the endoscopic findings, Crohn‘s disease was unlikely on account of the lack of longitudinal ulcer or cobblestone appearance. In addition, significant clinical improvement with corticosteroid therapy suggested sarcoidosis to other granulomatous diseases [5]. Furthermore, concomitant IMAGE OF THE ISSUE