A 62-year-old man was admitted for constitutional syndrome.
Personal history of type 2 diabetes mellitus and hyperuricemia treated with metformin and allopurinol.
It presents with weight loss, appetite loss and hypercalcemia.
Laboratory tests revealed Hb 9.9 mg/dl, eosinophils 7.5%, GGT 225 U/l, calcium 11.8 mg/dl, total proteins 7.2 g/dl, creatinine 1.5 mg/dl.
Normal rectum.
Antinuclear antibodies were negative.
Serology hepatitis, CMV, EBV, toxo, Aspergillus fumigatus, Brucella, negative; EBV Ig G positive, Coxiella Ig G positive, Candida Ig M negative.
High endoscopy, bronchoscopy, bronchoscopy, gammagraphy, proteinogram and bone marrow biopsy were normal.
Abdominal ultrasound and computed tomography revealed diffuse liver disease with signs of portal hypertension.
After treatment with furosemide and serum therapy, the calcemia levels initially worsened to 14.7 mg/dl. A liver biopsy showed non-necrotizing granulomas with epithelioid cells accompanied by fibrosis.
It consists of epithelioid, giant multinucleated cells (some microvaccinated) with plasma, mononuclear and polymorphonuclear cell component.
The inflammation surpasses the portal limiting, along with macrovesicular steatosis, neutrophils and eosinophils.
Ziehl negative.
Since the clinical picture was compatible with granulomas secondary to drugs, allopurinol and furosemide were removed.
At 3 weeks, mild hypercalcemia persisted (10.7 mg/dl). A short course of corticoids was decided, with normalization of calcemia and liver enzymes at 2 months.
Follow-up ultrasound at 4 months was normal.
