CASE PRESENTATION
The patient is a 61-year-old African American female with a history of diabetes mellitus type 2, hypertension, chronic kidney disease stage 4, obstructive sleep apnea, pulmonary sarcoidosis, hyperlipidemia and morbid obesity. She has been on chronic low-dose prednisone for management of pulmonary sarcoidosis. She presented for a screening colonoscopy and had no gastrointestinal symptoms. Colonoscopy revealed moderate diverticulosis of the colon, a 2 mm polyp in the ascending colon (Figure 1), two 2-4mm polyps in the transverse colon and external hemorrhoids.
QUESTIONS
1. What are some differential diagnoses of these polyps?
2. What would a pathology report of sarcoidosis show?
3. What are some possible gastrointestinal manifestations of this lesion?
4. What is the next step in the management of this patient?
DISCUSSION
Question 1.
The different types of colon polyps to consider include:
- Polyps that arise from submucosa including: lipomas, carcinoids, or lymphoid tissue1
- Mucosal polyps including:
○ Inflammatory polyps
○ Hamartomatous polyps including juvenile polyps, Peutz-Jeghers polyps, phosphatase and tensin homolog (PTEN) hamartoma tumor syndrome, and Cronkhite-Canada syndrome
○ Serrated polyps including hyperplastic polyps, sessile serrated polyps, traditional serrated adenomas, and serrated polyposis syndrome
○ Adenomatous polyps including tubular, villous, and tubulovillous
Further, there are very rare types of polyps including neurofibromal polyp of the colon and sarcoidosis of the colon. We present a patient with a history of pulmonary sarcoidosis who underwent a screening colonoscopy and was found to have a colon polyp with histology revealing sarcoidosis. Sarcoidosis is a granulomatous disease that causes noncaseating granulomas with multinucleated giant cells.2 Gastrointestinal (GI) involvement is rare and usually occurs subclinically.3
Question 2.
Pathology of the ascending colon polyp revealed nonadenomatous colonic mucosa with nodules of non-necrotizing, “hard,” well formed, noncaseating granulomas and nonspecific chronic inflammation, suggestive of sarcoidosis (Figure 2). There was no histologic evidence of TB, fungal infection, colitis, or foreign body reaction. Remainder of polyps revealed tubular adenomas without highgrade dysplasia.
Question 3.
In a patient with a history of sarcoidosis, it is important to be aware of the various manifestations. Clinically evident GI system involvement occurs in less than 1% of patients with sarcoidosis. Sarcoidosis may present anywhere in the gastrointestinal tract with a multitude of symptoms including obstruction, dysmotility, ulcer, heartburn, nausea, vomiting, pain, and weight loss caused by granulomatous infiltration in the mucosa and muscular layer.4
Question 4.
The optimal treatment for GI involvement is unknown because of the rarity of cases of GI sarcoidosis. Some cases had spontaneous remission and while other cases required glucocorticoid therapy.4 Since our patient did not have any clinical manifestations of gastrointestinal sarcoidosis, she continued on the treatment same dose of glucocorticoid for pulmonary manifestations of the disease.
References
1. Meseeha M, Attia M. Colon Polyps. 2019 Dec 16. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from http://www.ncbi.nlm.nih.gov/books/ NBK430761/ PubMed PMID: 28613512.
2. Levine MS, Ekberg O, Rubesin SE, Gatenby RA. Gastrointestinal sarcoidosis: radiographic findings. AJR Am J Roentgenol. 1989 Aug;153(2):293-5.
3. Friedman M, Ali MA, Borum ML. Gastric sarcoidosis: a case report and review of the literature. South Med J. 2007 Mar;100(3):301-3. Review. PubMed PMID: 17396736.
4. Ungprasert P, Ryu JH, Matteson EL. Clinical Manifestations, Diagnosis, and Treatment of Sarcoidosis. Mayo Clin Proc Innov Qual Outcomes. 2019 Aug 2;3(3):358-375. doi: 10.1016/j. mayocpiqo.2019.04.006. eCollection 2019 Sep. Review. PubMed PMID: 31485575; PubMed Central PMCID: PMC6713839.