Appendicular sarcoidosis is certainly a very uncommon cause of severe abdominal pain with just seven cases reported previously in the literature. History Sarcoidosis is certainly a chronic inflammatory granulomatous multisystem disease of unclear aetiology using a notably higher prevalence in African-American populations. A couple of two peaks of incidence; 25-35 and 45-65?years. Organs typically affected include the lungs lymph nodes and skin. Involvement of the gastrointestinal system although not uncommon is usually asymptomatic. In patients who are known to have sarcoidosis operative intervention should not be delayed because of the high risk of perforation. Case presentation A 45-year-old South Asian lady presented to the emergency department with a 1-week history of worsening epigastric and right upper quadrant pain with no associated vomiting or melena. Her medical history was significant for sarcoidosis a perforated duodenal ulcer a hiatus hernia early menopause following sterilisation and protein S deficiency. Her regular medications included hydroxychloroquine 200?mg once a complete time and lansoprazole 15? mg once a day. The patient experienced previously declined steroid immunosuppression for her sarcoidosis and warfarin for her protein S deficiency. On exam she was afebrile but tachycardic having a heart rate of 127 beats/min. She was initially tender in the epigastrium and right upper quadrant later on migrating to the right iliac fossa. Investigations The patient’s white cell count was 6.1??09 cells/l and C reactive protein was 59.7?mg/l. Her urea and electrolytes and liver function checks were normal except for a bilirubin PD318088 of 26?mg/dl. Urinalysis was unremarkable. Chest x-ray exposed bilateral hilar and right para-tracheal lymphadenopathy (number 1). Number?1 Chest radiograph demonstrating bilateral hilar lymphadenopathy suggestive of pulmonary sarcoidosis. Abdominal ultrasound shown free fluid PD318088 in the pouch of Douglas extending into the right iliac fossa where thickened loops of bowel were also mentioned. The appendix could not become visualised separately. Differential diagnosis Based on the history exam findings and results of investigations differential diagnoses of acute appendicitis ileocaecal tuberculosis salpingitis and tubo-ovarian abscess were considered. Treatment The patient was taken to theatre for any diagnostic PD318088 laparoscopy +/? appendicectomy. At operation a long retrocecal appendix was PD318088 found which appeared acutely inflamed and was eliminated along with free fluid in the pelvis. The gallbladder was distended and multiple granulomatous-looking lesions were seen in the liver. An omental mass was also found which was consequently biopsied HHIP within the suspicion of sarcoid granuloma. End result and follow-up Postoperatively a repeat ultrasound was performed which showed inhomogeneity of the liver and spleen suggesting early involvement by sarcoidosis. The patient’s symptoms resolved postoperatively and she was discharged home. The appendiceal specimen confirmed granulomatous inflammation the majority non-caseating and thus consistent with sarcoid (number 2). A Ziehl-Neelsen stain for was bad. Omental biopsy shown chronic inflammatory cells only. Figure?2 H&E micrograph at ×10 power of granulomatous swelling of appendix caused by sarcoidosis. Conversation Systemic sarcoidosis1 can typically impact any organ causing granulomas to form but predominantly affects the lungs. Common signs and symptoms include nonproductive cough fever weight loss chest pain ankle swelling lymphadenopathy erythema nodosum and vision pain/blurred vision. Typically sarcoidosis can be diagnosed via PD318088 a combination of cells biopsy (ie of palpable lymph nodes) and serum ACE levels. Standard treatments include corticosteroids immunosuppressants such as azathioprine or methotrexate and tumour necrosis element-α inhibitors such as infliximab. Symptomatic appendiceal sarcoidosis as explained in the above case is extremely rare: you will find seven instances to day reported in the literature.2-8 Of the three patients had a normal-looking appendix without proof inflammation.3 4 7 The various other four had swollen appendices with appendicitis verified on histology which three perforated.2 5 6 8 There are a variety of differentials for granulomatous irritation from the appendix notably Crohn’s disease tuberculosis histoplasmosis and Yersinia pestis infection. These could be indistinguishable on regimen histology and additional analysis may be required. 9 Tuberculosis could be eliminated with Ziehl-Neilsen histoplasmosis/Yersinia and staining pestis with culture. This is just the fourth.