Scar sarcoidosis with bone marrow involvement and associated musculoskeletal symptoms

Evaluation of sarcoidosis with multiple bone lesions using both bone scintigraphy and FDG-PET/CT: A case report

Sarcoidosis is a systemic granulomatous disease; however, the incidence of bone sarcoidosis is relatively rare. The short tubular bones of the hands and feet are most frequently affected, while the vertebrae and the pelvic bones are rarely involved. We hereby report a rare case of multiple bone sarcoidosis involving the vertebrae and pelvic bones, evaluated before and after steroid therapy using two different imaging modalities: bone scintigraphy and A 18F-fluorodeoxyglucose positron emission tomography combined with computed tomography (FDG-PET/CT). FDG-PET/CT is effective for detecting bone lesions; however, whole-body imaging is recommended to detect the short tubular bones of the hands and feet, which are most frequently affected.

Frontal cutaneous and bone sarcoidosis: an example of the contiguous spread of granulomas

Sarcoidosis is a multisystemic granulomatous disease of unknown origin. It has been argued that the skin is one of the entry doors of the possible antigen that causes sarcoidosis and after entering the skin, the causal agent may progress to the underlying bone. We report four cases with development of sarcoidosis in old scars located on the forehead, and contiguous bone involvement of the frontal bone. In most cases scar sarcoidosis was the first manifestation of the disease, and in most cases it was asymptomatic. Two patients never required treatment, and in all cases the frontal problem improved or remained stable spontaneously or under sarcoidosis treatment. Scar sarcoidosis in the frontal area may have contiguous bone damage. This bone involvement does not seem to be associated with neurological extension.

A Hypercalcemic Enigma: A Rare Case of Bone Marrow Sarcoidosis

Sarcoidosis is a multisystem inflammatory disease involving granuloma formation. The exact etiology of the disease remains unknown. While the lungs are the most commonly involved organs in sarcoidosis, bone marrow-only involvement is quite rare. As bone marrow-only involvement can have a presentation that closely resembles multiple myeloma, a significant diagnostic dilemma can occur as the treatment for sarcoidosis is different compared to multiple myeloma. We present a case of a 62-year-old female who presented with worsening lower extremity weakness and fatigue. She was found to have new-onset hypercalcemia, normocytic anemia, and lytic bony lesions. Extensive laboratory workup for multiple myeloma was negative with bone marrow biopsy showing non-caseating granulomas, thus diagnosing the patient with sarcoidosis involving the bone marrow.

A Rare Case of Relapsed Sarcoidosis Presenting As Severe Thrombocytopenia Associated With Intracerebral Hemorrhage Due to Bone Marrow Involvement

Sarcoidosis is a systemic granulomatous disease characterized by the hyperactivation of CD4 T cells, CD8 T cells, and macrophages. Clinical presentations of sarcoidosis are highly variable. Sarcoidosis is unknown in its etiology, but it suggests it may result from exposure to specific environmental agents in genetically susceptible people. Sarcoidosis commonly involves the lungs and lymphoid system. Bone marrow involvement in sarcoidosis is uncommon. Sarcoidosis rarely results in intracerebral hemorrhage due to severe thrombocytopenia secondary to bone marrow involvement. We present the case of a 72-year-old woman who has been in remission from sarcoidosis for 15 years and developed intracerebral hemorrhage secondary to severe thrombocytopenia due to sarcoidosis recurrence in the bone marrow. The patient presented to the emergency department with a generalized, non-blanching petechiae rash and nose and gum bleeding. Her labs showed a platelet count of less than 10.000/mcL, and computed tomography (CT) showed intracerebral hemorrhage. A bone marrow biopsy revealed a small, non-caseating granuloma indicative of a sarcoidosis relapse in the bone marrow.

Sarcoidosis with Rare Extrapulmonary Involvement

Sarcoidosis is a systemic granulomatous disease in which medullary involvement is a rare extrapulmonary manifestation. We present the case of a 37-year-old man with right abdominal and dorso-lumbar pain lasting for months. Computerized tomography showed renal microlithiasis and retroperitoneal, hilar and mediastinal adenopathies. Laboratory results showed an elevated erythrocyte sedimentation rate, IgG, β2-microgobulin and angiotensin-conversion enzyme, serum calcium in the upper limit and hypercalciuria. There was a slight elevation of the CD4/CD8 ratio in bronchoalveolar lavage, without lymphocytic alveolitis. An endobronchial ganglion biopsy was inconclusive. A positron emission tomography scan demonstrated supra and infra-diaphragmatic, splenic and medullary involvement, suggesting lymphoproliferative disease (LPD). A bone marrow biopsy (BMB) revealed sarcoid-like epithelioid cell granulomas, excluding LPD. Sarcoidosis was assumed and corticosteroids were started. Although cytopenias were not present, the extensive ganglion, splenic and medullary involvement made LPD exclusion imperative, while BMB allowed for a definitive diagnosis.

LEARNING POINTS

Sarcoidosis is a multisystemic granulomatous disease in which medullary involvement is a rare extrapulmonary manifestation.Bone marrow biopsy is rarely performed based on serial blood counts, which may be associated with underdiagnosis.FDG-PET cannot reliably distinguish between sarcoidosis and lymphoproliferative disease as the cause of extensive ganglion, splenic and bone marrow involvement, and so a high index of clinical suspicion is required.

Bone marrow involvement: Atypical presentation of early-onset childhood sarcoidosis

Childhood sarcoidosis is a chronic multisystemic, non-caseating granulomatous disease of unknown etiology. Early-onset disease classically presents with a triad of skin rash, uveitis, and arthritis, but bone marrow involvement is rare. We report a 9-1/2-year old Indian female child who presented with bleeding manifestation, skin rash, uveitis, and arthritis. Bone marrow biopsy showed multiple non-necrotizing granulomas comprising epithelioid cells, mature lymphocytes, and multinucleated giant cells with few eosinophils in the background, with negative staining for acid-fast bacilli or fungi. She was treated successfully with oral prednisolone. This is the first report of an early-onset childhood sarcoidosis with bone marrow involvement from India.

Bone Marrow Sarcoidosis with Pancytopenia and Renal Failure Presenting as Fever of Unknown Origin: The Pivotal Role of 18F-FDG PET/CT in Lesion Detection

We describe a case of fever of unknown origin (FUO), renal failure, and pancytopenia. Initially, lymph proliferative disorder was suspected; therefore, bone marrow biopsy and 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) were performed. Bronchoscopy and lung biopsy were performed because of abnormal FDG uptake in both lung fields. Imaging data and laboratory and histological results confirmed sarcoidosis with bone marrow invasion. The patient was discharged after favorable response to corticosteroid therapy. Sarcoidosis may present as FUO without typical specific presentations in the skin or lungs. Combined 18F-FDP PET/CT helped identify the biopsy site and confirmed the sarcoidosis diagnosis.