A Case of Hypercalcemia Due to Peritoneal Sarcoidosis Presenting as Appendicitis and Recurrent Sterile Intra-abdominal Abscess with Skin Fistula

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Introduction: Sarcoidosis is a systemic inflammatory disease which affects multiple organs. The lungs and lymphatic systems are most commonly affected. We present a case of peritoneal involvement. Case Description: A 47 year old man who had no prior history presented to ED with sudden onset abdominal pain, was diagnosed with acute appendicitis, and underwent laparoscopic appendectomy. The hospital course was complicated by intermittent fevers without leukocytosis, sterile intraabdominal pus like fluid collection and provoked pulmonary embolism. He was discharged with indwelling intraabdominal Jackson-Pratt drain and oral metronidazole. One month later, he presented with abdominal pain, swelling at the surgical site and 20 lbs weight loss. His serum calcium was 16.3, repeated CT abdomen and pelvis revealed mass-like consolidation along the right anterior greater omentum, multiple intra-abdominal rim-enhancing fluid collection (see image). Hypercalcemia workup showed: PTH 8.4, PTHrP <2.0, 25OH VitD 7.03 and 1,25OH VitD 101, ACE level 176. Due to high suspicion of granulomatous disease all infectious causes and malignancy were ruled out with peritoneal fluid cytology. Omental biopsy was done which showed Fibro adipose tissue with non-necrotizing granulomas, Acute and Chronic inflammation with Giant cell reaction (see image). He was diagnosed with sarcoidosis and started on Prednisone after which he clinically improved and hypercalcemia resolved Discussion: As sarcoidosis is a diagnosis of exclusion, sometimes diagnosing sarcoidosis can be challenging because of its indolent nature, and similar presentation to inflammatory, chronic infectious diseases or malignancy. Peritoneal involvement of sarcoidosis is a rare manifestation.

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