Hepatic granulomas may be observed on liver biopsies from patients with hepatitis C[7
], hepatitis B[9
] and hepatitis A[10
]. The incidence of hepatic granulomas in chronic HCV has been estimated at between 1%[7
] and 10%[8
]; in chronic HBV it is about 1.5%[9
]. However, sarcoidosis complicating chronic viral hepatitis is rare. A number of case reports describe hepatic sarcoidosis in patients receiving antiviral treatment for HCV[12
]. Here we report two cases of sarcoidosis complicating treatment-naïve chronic HBV and HCV. Sarcoidosis in untreated HBV is previously unreported.
Causes of hepatic granulomas include sarcoidosis, primary biliary cirrhosis, autoimmune hepatitis, drug-induced hepatotoxicity, lymphoma, viral hepatitis, tuberculosis, cytomegalovirus, leishmaniasis, toxoplasmosis, Q fever, fungal infections and antiviral treatment such as interferon, ribavirin and amantidine[8
]. As for our patients, the diagnosis of hepatic sarcoidosis relied on demonstration of non-caseating granulomas and exclusion of other causes[22
]. Whilst HCV and HBV may cause granulomatous hepatitis[7
], the elevated serum ACE levels, extensive lymphadenopathy and steroid responsiveness supports a diagnosis of sarcoidosis in both cases.
The majority of patients with hepatic sarcoidosis are asymptomatic and the general consensus is to reserve treatment for patients with abnormal liver biochemistry[23
]. Our cases fulfilled this criterion and deomonstrated normalization of liver tests with steriod therapy. For case 1, abnormal liver biochemistry persisted despite HBV supression and then resolved with steroid therapy. For case 2, it was felt that the ALT level was much higher than what is usually seen in chronic HCV with moderate disease alone. This high ALT level and features of marked granulomatous hepatitis on liver biopsy led to initial therapy to be directed at sarcoidosis as this was considered to constitute the primary cause of liver injury. The ACE level dropped and liver biochemistry normalized with steroid therapy, even before the commencement of anti-viral therapy. Previous reports have documented a relapse of sarcoidosis with interferon treatment of HCV[15
]. However, our patient (case 2) underwent successful therapy with pegylated interferon and ribavirin without such relapse.
In conclusion, hepatic sarcoidosis in combination with chronic viral hepatitis is uncommon. Our cases demonstrate that immune suppressive therapy in combination with appropriate timed antiviral therapy can be successful.