Disseminated Mycobacterium Avium Complex Mimicking Multi-Organ Sarcoidosis in a Patient with Systemic Lupus Erythematosus Treated with Rituximab

A 38-year old female with a history of systemic lupus erythematosus on rituximab therapy, bipolar dis-order, renal dysfunction, and recurrent nephrolithiasis, presented to the hospital with fevers, flank pain, 40-pound weight loss, odynophagia, and dysphagia. She was found to have new pancytopenia, pulmonary nodules and ground glass opacities on chest CT, and low-grade disseminated intravascular coagulation. She was treated with broad spectrum anti-microbials without improvement, and when her respiratory status rapidly declined, she was empirically started on steroids and quickly improved. After extensive workup, her overall clinical picture supported the diagnosis of sarcoidosis with pulmonary nodules, alkaline phosphatase elevation, hypercalcemia, elevated angiotensin converting enzyme and soluble IL-2 receptor level, and non-necrotizing granulomas on liver biopsy. Shortly after discharge, polymerase chain reaction of respiratory tract and blood cultures taken during hospitalization resulted positive for mycobacterium avium complex, consistent with disseminated Mycobacterium avium complex infection mimicking multi-organ system sarcoidosis. biopsy in cellularity atypical lymphoid granulomas. aspirate histiocytes ingested red blood cells no increase in hemophagocytosis of nucleated cells. Liver biopsy showed macro-vesicular steatosis and non-necrotizing portal and lobular granulomas. Soluble IL-2 was elevated at 27,600 (reference <1,000).