Osseous sarcoid with lytic lesions in skull

Osteolytic sarcoidosis of the orbit without pulmonary involvement

A 69-year-old woman with a history of a left orbital mass presented to the emergency room with progressive breakthrough pain in her left orbit despite medical therapy. On examination, there was extraocular motility restriction with diplopia upon left supraduction. Computed tomography (CT) scan of the orbits revealed soft tissue thickening of the left medial and superior periorbita and left lacrimal fossa; bony erosion of the left frontal bone, left orbital roof, and left lamina papyracea; and bilateral mass-like enlargement of the extraocular muscles. An orbitotomy with incisional biopsy was performed, and histopathological examination revealed non-caseating granulomatous inflammation consistent with sarcoidosis. Chest imaging demonstrated no sequela of pulmonary sarcoidosis, and her serum angiotensin converting enzyme (ACE) level was within normal range. She was treated with high-dose oral steroids with resolution of her symptoms. Her pain returned at the conclusion of the steroid taper, and it was controlled with chronic subcutaneous methotrexate and adalimumab injections.

Extensive bony sarcoidosis of the head and neck region: a rare presentation

We present a rare case of sarcoidosis with extensive bony destruction of the maxillofacial and skull base bones. A 65-year-old woman was referred with an asymptomatic, non-healing dental socket. Examination revealed an oroantral fistula that was biopsied and repaired under general anaesthesia. Investigations included plain and cross-sectional imaging. Serological tests, in particular ACE, were normal. Histology showed benign florid granulomatous inflammation. At 6 months, the patient remained asymptomatic. She was re-referred 3 years later with further bony destruction of her maxilla and mandible. Repeat imaging showed intrathoracic lymphadenopathy and skull base involvement. Repeat biopsy confirmed granulomatous inflammation. Given the pulmonary, histological and radiological findings, a sarcoidosis diagnosis was made. Following multidisciplinary team meetings, the patient was treated with methotrexate and arrangements made for close monitoring. This case highlights the need for a consensus in identifying, treating and developing a follow-up protocol in such patients.

Sarcoidosis of the Skull: A Systematic Review

BACKGROUND

Lesions of the skull make up a small but important part of neurosurgical practice. Several systemic disorders may involve the cranial vault including neoplastic and non-neoplastic conditions. Sarcoidosis of the skull is a little-known cause of calvarial involvement that has been rarely reported in the literature. The available information about skull sarcoidosis (SS) is sparse and is not well described; for this reason, we consider that a detailed description of this uncommon condition is necessary.

METHODS

An illustrative case of SS is presented; in addition, a PubMed and Scopus search adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed to include studies reporting patients with SS. Different information was analyzed in these cases to describe the characteristics of this condition. Also, different sources of literature were analyzed to complete the description of this clinical entity.

RESULTS

The search yielded 22 cases of patients with SS showing a variety of clinical manifestations. All studies were case reports. Most patients diagnosed with SS had no previous history of systemic sarcoidosis. Different characteristics of SS are analyzed and described in this paper.

CONCLUSIONS

The information collected from this review shows that SS is a rare condition that frequently is observed in patients without previous diagnosis of sarcoidosis. SS may manifest in different ways, and even may be found incidentally in some patients. The diagnosis of SS should be considered when multiple lytic skull lesions are observed, especially in cases of patients without a previous history of malignancy.

Sarcoid Infiltration of the Skull with Epidural Extension: Case Report and Literature Review

BACKGROUND

Sarcoidosis is a granulomatous disease most often affecting the lungs, but extrapulmonary manifestations are also common. While virtually any organ system can be involved, skeletal manifestations are present in 1%-13% of cases. Skull lesions are even more rare. We found 14 case reports describing symptomatic skull lesions in patients with no prior history of sarcoid to better understand the symptomology and disease progression.

CASE DESCRIPTION

Here we present the case of a 57-year-old female with history of sarcoidosis and new-onset forgetfulness, confusion, and headaches who was found to have multiple skull lesions with epidural extension. On histopathologic examination of the excised lesion, noncaseating granulomas were observed and diagnoses of skull sarcoidosis and neurosarcoid were made. Since the patient was actively treated with corticosteroids, the plan was to initiate infliximab.

CONCLUSION

Sarcoidosis affecting the skull and central nervous system is exceedingly rare and can mimic many pathologies including metastatic bone disease, multiple myeloma, and eosinophilic granulomatosis. With a wide differential, surgical specimen is needed for concrete diagnosis and treatment. While the rates of skeletal involvement are low, a skeletal survey might be an important step in monitoring disease burden in patients, especially as lesions can be asymptomatic.

Radiological review of skull lesions

Abstract

Calvarial lesions are often asymptomatic and are usually discovered incidentally during computed tomography or magnetic resonance imaging of the brain. Calvarial lesions can be benign or malignant. Although the majority of skull lesions are benign, it is important to be familiar with their imaging characteristics and to recognise those with malignant features where more aggressive management is needed. Clinical information such as the age of the patient, as well as the patient’s history is fundamental in making the correct diagnosis. In this article, we will review the imaging features of both common and uncommon calvarial lesions, as well as mimics of these lesions found in clinical practice.

Teaching Points

• Skull lesions are usually discovered incidentally; they can be benign or malignant.

• Metastases are the most frequent cause of skull lesions.

• Metastatic lesions are most commonly due to breast cancer in adults and neuroblastoma in children.

• Multiple myeloma presents as the classic “punched out” lytic lesions on radiographs.

• Eosinophilic granuloma is an osteolytic lesion with bevelled edges.

Osteolytic Sarcoidosis of the Orbital Roof Masquerading as a Malignant Orbital Lesion

A 51-year-old man without a significant past medical history presented with 4 weeks of progressive swelling and drooping of his left upper eyelid. A CT of the left orbit revealed an osteolytic mass lesion in the area of the lacrimal gland. A left orbitotomy with excisional biopsy was performed. The excised tissue was sent for infectious workup and histopathological examination, which revealed osteolytic sarcoidosis. The patient was treated with systemic and local injection corticosteroids, and followed over 10 months without evidence of recurrence. Systemic workup with CT of his chest, abdomen, and pelvis revealed no further evidence of sarcoidosis. To the best of the authors knowledge, this is the first report of an otherwise healthy patient presenting with isolated osteolytic sarcoidosis of the orbit and a negative systemic workup.

Sarcoidosis with prevalent and severe joint localization: a case report

Background

Sarcoidosis is a systemic granulomatous disease of unknown origin, characterized by the formation of granulomas without central necrosis. Each organ and tissue can be affected by the disease, but in most cases mainly the lungs and mediastinal lymph nodes but also skin, heart, eyes and joints are involved, the latter are mainly the metacarpophalangeal joints and bone lesions are often associated with involvement of the overlying skin. The diagnosis is often of exclusion, based on clinical and radiological suspicion, and should be confirmed by biopsy, although in each case it is necessary to exclude other possible causes of granulomatosis, including infections by mycobacteria. Here it is reported a case of particularly aggressive sarcoidosis with primitive involvement of the small joints of the hands and feet, and mediastinal lymph nodes.

Case presentation

The subject, a man, 60 years old, born in Morocco but living in Italy for many years, presented important involvement of bone structures and soft periarticular tissue, and was affected by the formation of granulomas without “caseum necrosis”. The painful symptoms and the skin ulceration had led to surgical amputation of the distal phalanges of most fingers of his hands and feet, but with subsequent resurgence of lesions in acral locations after surgery. The PET/CT scan showed an amount of radiotracer in mediastinal lymph nodes, while the lymph nodes sampled by TBNA were normal and the CD4/CD8 ratio was less than 3 in the bronchoalveolar lavage. We ruled out any possible infectious cause, including mycobacterial infection (both tubercular and atypical), so the patient was treated with systemic corticosteroids, with an excellent clinical and radiological response.

Conclusions

Such a case shows how the disease can have variable expressions, without primitive lung involvement; therefore, it should be necessary to consider any possible, unpredictable localization of the disease.

Neurosarcoidosis: clinical review of a disorder with challenging inpatient presentations and diagnostic considerations

Neurosarcoidosis is frequently on the differential diagnosis for neurohospitalists. The diagnosis can be challenging due to the wide variety of clinical presentations as well as the limitations of noninvasive diagnostic testing. This article briefly touches on systemic features that may herald suspicion of this disorder and then expands in depth on the neurological clinical presentations. Common patterns of neurological presentations are reviewed and unusual presentations are also included. A discussion of noninvasive testing is undertaken, exploring dilemmas that may be encountered with sensitivity and specificity. Drawing from a broad range of clinical clues and diagnostic data, a systematic approach of pursuing a potential tissue diagnosis is then highlighted. Correctly diagnosing neurosarcoidosis is critical, as treatment with appropriate immunosuppression protocols can then be initiated. Additionally, treatment of refractory disease, the trend toward exploring targeted immunomodulation options, and other therapeutic issues are discussed.