A diagnostic dilemma: Differentiating hepatic sarcoidosis from DRESS syndrome in a patient with acute liver injury

Introduction

If unexplained acute liver injury symptoms imply several overlapping etiologies, diagnostic difficulty can ensue. Less frequent diseases like hepatic sarcoidosis and DRESS syndrome need to be included in differential diagnosis, but drug-induced liver injury and viral hepatitis are frequent etiologies.

Presentation of the case

A 28-year-old woman patient presented with pruritic rash, jaundice, and right upper quadrant pain for one month. Laboratory tests showed eosinophilia (520 cells/μL), hyperbilirubinemia (6.20 mg/dL), hepatocellular injury (AST 401 U/L, ALT 351 U/L), and highly raised ACE levels (216 U/L). Imaging revealed mediastinal lymphadenopathy. The patient's liver enzymes and symptoms significantly improved with corticosteroid treatment.

Discussion

Because DRESS syndrome and hepatic sarcoidosis share clinical and biochemical characteristics, the diagnostic challenge of differentiating between the two conditions is brought about in this case. While temporal drug association and eosinophilia predisposed towards drug hypersensitivity, the raised ACE levels and lymphadenopathy pushed in the direction of granulomatous disease. The shared immune-mediated pathophysiology of the two diseases was emphasized by the steroid response.

Conclusion

In the assessment of acute liver injury with systemic manifestations, this case emphasizes the need to rule out both drug hypersensitivity and granulomatous disease. It draws attention towards the need for improved diagnostic markers while also recognizing the utility of serum ACE testing and imaging in these situations. The case highlights the advantage of interdisciplinary management in difficult hepatology patients and the effectiveness of corticosteroids.

Key clinical message

This case demonstrates the difficulty of making a distinction between hepatic sarcoidosis and drug-induced liver damage in cases where the two diseases mimic each other. Both etiologies must be considered in cases of unexplained acute liver injury with systemic symptoms. Although corticosteroids can be an effective treatment of immune-mediated disease, prolonged follow-up is indicated. Interdisciplinary collaboration enhances the treatment of such complex cases and the validity of diagnoses.