A 36-year-old woman comes to the office due to arthralgias and nodules on her legs. She has no prior medical conditions and takes no medications. On physical examination, there is moderate hepatomegaly. A representative skin rash is shown in the image below. The lesions are tender and present predominantly on the anterior surface of the lower extremities. Chest x-ray demonstrates enlarged hilar lymph nodes, and laboratory testing reveals an elevated ACE level. Which of the following would most likely be found on liver biopsy in this patient?

Question

A 36-year-old woman comes to the office due to arthralgias and nodules on her legs.  She has no prior medical conditions and takes no medications.  On physical examination, there is moderate hepatomegaly.  A representative skin rash is shown in the image below.  The lesions are tender and present predominantly on the anterior surface of the lower extremities.  Chest x-ray demonstrates enlarged hilar lymph nodes, and laboratory testing reveals an elevated ACE level.  Which of the following would most likely be found on liver biopsy in this patient?

Quizplus · Accepted Answer

11ec160b_3a1c_f441_9249_4d31ae0715a6_MD0001_00 This patient has tender erythematous nodules on the anterior lower extremities, consistent with erythema nodosum, a nonspecific, delayed hypersensitivity reaction that can be seen in a variety of infections or inflammatory disorders. However, in combination with hilar adenopathy and elevated ACE levels (formed by activated macrophages), this presentation is highly suggestive of sarcoidosis. Sarcoidosis is a systemic inflammatory disorder of unknown etiology characterized pathologically by noncaseating granulomas. Granulomas can occur in any organ but commonly involve the lymph nodes (eg, bilateral hilar adenopathy), lungs (interstitial lung disease), joints (eg, arthralgias), eyes (uveitis), or skin. Most patients with sarcoidosis also develop liver involvement, typically in the form of asymptomatic hepatomegaly with mild liver function test abnormalities (alkaline phosphatase > aminotransferases). Biopsy will show scattered noncaseating granulomas, predominantly around the portal veins. (Choice A) Centrilobular necrosis is the death of hepatocytes immediately surrounding the terminal hepatic vein. Ischemic injury (as in right-sided heart failure), drugs, toxins, and fulminant hepatitis can be responsible. (Choice B) Fatty change (steatosis) is most commonly seen in alcohol use or obesity, although it can also be seen with a reversible hypoxic, toxic, or metabolic injury (eg, protein malnutrition). (Choice C) Nodular regeneration is seen with cirrhosis. Sarcoidosis does not typically progress to hepatic cirrhosis. (Choice D) Periportal fibrosis may be seen in chronic cholestasis (eg, primary sclerosing cholangitis, primary biliary cholangitis) or chronic viral hepatitis; it is not associated with sarcoidosis. (Choice E) Portal inflammation is a very nonspecific finding that occurs with many forms of hepatitis, toxin- and drug-induced liver injury, and metabolic and cholestatic liver diseases. Educational objective: Sarcoidosis is a systemic inflammatory disorder characterized by noncaseating granulomas in a variety of tissues. Most patients develop liver involvement, which typically manifests as asymptomatic hepatomegaly with mild liver function test abnormalities. Liver biopsy frequently demonstrates scattered noncaseating granulomas.

A 36-Year-Old Woman Comes to the Office Due to Arthralgias