Bone sarcoidosis

Radiographical bony lesions after discontinuation of immunosuppressant therapy: bone involvement in sarcoidosis

We describe a patient who had failed renal transplant after 13 years, eventually requiring a graft nephrectomy and discontinuation of immunosuppressive therapy, including antithymocyte globulin, tacrolimus and mycophenolate while on steroid avoidance protocol. Within a few months of complete discontinuation of the immunosuppressive medications, she developed lower back pain associated with numbness in her right anterolateral thigh. The radiological imaging demonstrated multiple bony lesions throughout her axial and appendicular skeleton with normal pulmonary findings. A computerised tomography-guided bone biopsy from the left iliac crest revealed fragments of bone with granulomatous inflammation, thus making the diagnosis of extrapulmonary sarcoidosis. Initiating treatment with prednisone resulted in near-complete resolution of symptoms. Long-term immunosuppressive therapy is administered to all renal transplant recipients to help prevent acute rejection and loss of renal allograft. This case highlights that immunosuppressants can conceal the presence of underlying conditions in transplant patients.

Phalangeal sarcoidosis - A rare case report

We report a case of a 57-year-old woman who presented a rapidly progressing swelling at the base of her right 4th finger, with imaging revealing non-specific lesions suggestive of a malignant tumoral process. Following imaging, resection-biopsy revealed a non-caseating granulomatous inflammatory infiltrate suggesting sarcoidosis. Digital sarcoidosis is an uncommon presentation of the disease, especially in the early stages and without systemic symptoms. Early diagnosis and treatment are advised in order to prevent future complications.

Phalangeal microgeodic syndrome: a paediatric case series

We present the clinical and radiological characteristics of phalangeal microgeodic syndrome in a cluster of five children during the second peak of COVID-19 pandemic in the UK. Each child presented with phalangeal swelling and erythema, prompting a comprehensive multi-disciplinary team review to analyse the clinical presentation, blood test results and imaging. The cohort's average age was 14.1 years, ranging from 10.4 to 16.6 years, with two girls and three boys. Four children experienced phalangeal involvement in the hands, whilst one was affected solely in the feet. A rheumatological work-up was performed for all. Hand X-rays performed on three children revealed distinct radiographic features like microgeodes, subperiosteal bone resorption and rarefaction in two cases. However, further MRI showed extensive changes closely correlated with the clinical signs of cutaneous vasculopathic rashes. The MRI abnormalities were notable, encompassing marrow oedema primarily affecting metaphyses and epiphyses, displaying broad transition zones. Soft tissue swelling and cortical erosions were also observed. These MRI features proved more pathognomonic in the acute clinical context. The study concluded that phalangeal microgeodic syndrome, characterised by digital swelling and erythema, might not be adequately assessed by plain X-rays. The more comprehensive MRI features, including marrow oedema and soft tissue abnormalities, appeared to be more indicative in diagnosing the condition. Considering the rarity of this syndrome and its temporal association with the COVID-19 pandemic, the study hypothesised that COVID-related thrombophilia and immune-mediated vasculopathy might act as crucial triggers for the active bony manifestations seen in this syndrome. KEY POINTS: • PMS is a rare, predominantly paediatric condition, of unknown aetiology which affects the digits. • Laboratory investigations are generally negative; however, in the appropriate clinical context, the X-ray findings of microgeodes and pattern of bone marrow oedema seen on MRI are pathognomonic. • Considering the rarity of PMS and temporal association with the COVID-19 pandemic, COVID vasculopathy may represent a previously unrecognised aetiology for PMS.

Sarcoidosis with Severe Bone Involvement: A Case Report and Literature Review

Sarcoidosis is a systemic granulomatous disease of the lungs that commonly involves intrathoracic lymph nodes. Here, we report the case of a 68-year-old woman who complained of shortness of breath and had suffered from the enlargement of intrathoracic lymph nodes for 12 years, swelling of the right middle finger for 7 years, and nasal obstruction for 2 years. The damage to the phalange was aggravated continuously and a malignant lesion could not be excluded, thus leading to amputation of the right middle finger. Pathological data indicated chronic inflammatory granulomatous disease and anti-acid staining was negative. Examination of the paranasal sinuses indicated destruction of the sinonasal bone and the swollen mucosa. Combined with the elevated ratio of CD4+/CD8+ T cells in bronchoalveolar lavage fluid and other results, the patient was finally diagnosed with sarcoidosis and received corticosteroid therapy. The shortness of breath and abnormality of the nose were significantly improved after treatment. Our case demonstrated the process of differential diagnosis for systemic granulomatous diseases, indicating the necessity of corticosteroid therapy for systematic sarcoidosis.

Imaging Plays a Key Role in the Diagnosis and Control of the Treatment of Bone Sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of unknown origin. The most frequent localizations are thoracic lymph nodes and/or parenchymal lung disease, nevertheless any other organ may be involved. Musculoskeletal sarcoidosis, previously considered a rare manifestation of the disease, is presently recognized with increasing frequency, due to the development of modern imaging modalities. The classical X-ray sign of bone sarcoidosis is the image of lace in the phalanges of the hands. Most other locations present with atypical radiological images. Therefore, they may mimic metastatic neoplastic disease, especially when they are the first sign of sarcoidosis not previously recognized. On such occasions, none of the imaging methods will give the correct diagnosis, histopathological verification, monitoring of lesions or clinical data in a patient with confirmed sarcoidosis are indicated. The article summarizes the current status of knowledge concerning the recognition and therapy of bone sarcoidosis. In addition, an illustrative case of patient with bone and bone marrow sarcoidosis is presented.

Autoantibody profile in sarcoidosis, analysis from the GRADS sarcoidosis cohort

BACKGROUND

Sarcoidosis, a multi-systemic granulomatous disease, is a predominantly T-cell disease but evidence for a role for humoral immunity in disease pathogenesis is growing. Utilizing samples from the Genomic Research in Alpha-1 anti-trypsin Deficiency and Sarcoidosis (GRADS) study, we examined the prevalence of autoantibodies in sarcoidosis patients with pulmonary-only and extra-pulmonary organ involvement compared to normal controls.

STUDY DESIGN AND METHODS

We analyzed serum samples from sarcoidosis patients who participated in the GRADS study utilizing an autoantigen microarray platform for both IgM and IgG antibodies. The cohort included sarcoidosis patients with pulmonary-only disease (POS, n = 106), sarcoidosis patients with extra-pulmonary disease (EPS, n = 120) and a normal control cohort (NC, n = 101). Organ involvement was assessed following a standardized format across all GRADS participating centers.

RESULTS

Sarcoidosis patients overall had increased levels of IgM and IgG autoantibodies compared to normal controls. In addition, several autoantibodies were elevated in the POS and EPS cohorts compared to the NC cohort. Differences in autoantibody levels were also noted between the POS and the EPS cohorts. When comparing organ involvement with sarcoidosis, bone, spleen and ear, nose and throat involvement had higher IgM expression than other organs.

CONCLUSION

Sarcoidosis patients have elevated IgM and IgG autoantibody levels compared to normal controls. In addition, individuals with pulmonary as well as additional organ involvement had higher IgM expression. Further research is needed focusing on specific organ-autoantibody pairs and role of autoantibodies in disease pathogenesis.

Musculoskeletal Manifestations of Sarcoidosis

Since its initial description in the late 19th century, sarcoidosis has been extensively studied. Although the general mechanism of immune activation is known, many details especially in the context of disease associations are still missing. One of such associations is the musculoskeletal complications that are widely variable in terms of presentation and response to treatment. Sarcoidosis can involve the joints leading to acute and, less commonly chronic, arthritis. While acute arthritis is mostly self-resolving in nature, chronic arthritis may lead to deformity and destruction of the joint. Sarcoidosis can also involve the muscles, leading to different pathologies primarily categorized according to the clinical presentation, despite the efforts to find a new classification based on imaging, histological, and clinical findings. The bones can be directly and indirectly affected. Different types of bone lesions have been described, although around half of these patients remain asymptomatic. Osteoporosis, increased risk of fractures, hypercalcemia, and hypercalciuria are examples of the indirect effect of sarcoidosis on the bones, possibly contributed to elevated levels of calcitriol. Nevertheless, sarcoidosis can be associated with small-vessel, medium-vessel, and large vessel vasculitis, although it is frequently difficult to differentiate between the co-existence of a pure vasculitis and sarcoidosis and sarcoid vasculitis.

A Rare Presentation of Intraosseous Sarcoidosis of the Mandible Presenting as Peri-Implantitis: A Case Report and Literature Review

PURPOSE

We describe a rare case of intraosseous sarcoidosis initially presenting as peri-implantitis, perform a review and analysis of 27 cases of intraosseous sarcoidosis, and provide a clinical review of this condition.

METHODS

We searched the literature for patients presenting with intraosseous sarcoidosis of the jaw through June 2020 using key phrases. Additional papers were included via a search of references and citing papers. Data including patient demographic characteristics and diagnostic tests were manually extracted from the cases and then qualitatively coded by the authors. Descriptive statistical analysis was performed to elucidate general themes and characteristics.

RESULTS

A total of 27 cases, dating as early as 1943 and as recent as this case, were identified in the literature, including our case. The average age of these patients was 39 years old, with a range of 16 to 75 years. Eighteen (67%) cases were identified as female and nine (33%) as male. Fourteen cases were reported with localized mandibular involvement. Ten had maxillary disease; 3 cases were generalized to both regions. Nine cases presented anteriorly, 12 posteriorly, and 6 extended across both regions. Eight patients received surgical interventions, such as tooth extractions or lesion removal. Five patients received nonsurgical interventions, such as steroids. Ten patients received combination therapy, often involving surgical intervention and steroid therapy.

CONCLUSION

Our patient had an unusual presentation of intraosseous sarcoidosis mimicking peri-implantitis. To our knowledge, no case in the English literature describes a patient with sarcoidosis presenting with peri-implantitis. Based on the literature review and analysis of our patient's experience, sarcoidosis should be considered on the differential diagnosis for patients with persistent, nonhealing bony lesions in the maxillofacial region, particularly when patients have not been exposed to osteoclast inhibitory therapy or radiation. Pathologic analysis of bone and surrounding tissue in these scenarios is essential.

Metastasis of lung cancer?

BACKGROUND

Sarcoidosis is a multi-system, idiopathic, inflammatory disorder that affects the lungs in over 90% of patients. The incidence of bone lesions in sarcoidosis is only 1-13%.

CASE REPORT

This study describes a 60-year-old woman with a previous history of thyroid cancer, and a more recent diagnosis of lung cancer with suspicious metastatic lesions, which were confirmed to be sarcoidosis.

CONCLUSION

This case suggests that pulmonary neoplasms and pulmonary sarcoidosis can coexist and be easily confused. When lung cancer is accompanied by symmetric hilar lymph node enlargement and multiple lung nodules, sarcoidosis should be considered in addition to metastasis, and a biopsy should be performed for confirmation.

Disseminated sarcoidosis involving lymph nodes, bone and spleen with progressive cardiac sarcoidosis on 18F-FDG PET/CT and cardiac MRI

A 63-year-old lady with a background of ischemic heart disease was referred for ¹⁸F-FDG PET/CT for multiple lytic bone lesions which showed disseminated FDG avid lesions in the skeleton, nodal stations as well as spleen simulating advanced malignancy such as diffuse lymphomatous disease. A diagnosis of sarcoidosis was pathologically confirmed with bone biopsy. Following treatment, repeat PET/CT revealed significant regression of FDG avid lesions, however prominent uptake in the lateral ventricular wall was suspicious for active cardiac sarcoidosis, particularly given recurrent chest pain. This was confirmed on cardiac MRI and correlation with PET enabled discrimination between ischemic and non-ischemic fibrosis.

A rare case of atypical bone marrow sarcoidosis without pulmonary involvement in a Japanese woman

Sarcoidosis is a systemic granulomatous disease of unknown origin characterised by the presence of non-caseating granulomatous lesions. Extrapulmonary sarcoidosis with bone marrow involvement is rare and even more so without pulmonary involvement. Here, we describe a case of 69-year-old woman diagnosed as having bone marrow and hepatic sarcoidosis without pulmonary involvement based on ¹⁸F-fluorodeoxyglucose positron emission tomography findings. She was successfully treated with systemic glucocorticoid therapy.

Case report of osteolytic lesions in a patient with multisystem granulomatous disease

We present a case of a 70-year-old Caucasian woman with multisystem granulomatous disease involving her lungs, bones and lymph nodes. The patient initially presented with cervical lymphadenopathy and subsequently developed progressive breathlessness. Imaging revealed extensive mediastinal, hilar and intra-abdominal lymphadenopathy as well as bilateral pulmonary parenchymal infiltrates. Lymph node and lung biopsy confirmed non-necrotising granulomatous inflammation while a BAL showed scanty growth of Cryptococcus neoformans and moderate growth of Staphylococcus aureus The patient received intravenous ceftriaxone and had a good response to treatment. She also completed 3 months of oral fluconazole. Although a diagnosis of sarcoidosis was considered most likely, the patient was not initially started on systemic corticosteroids due to concern around possible infection and initial response to antimicrobials. However, her exercise tolerance gradually deteriorated. A craniofacial CT revealed multiple lytic lesions involving the skull and visualised cervical spine. Biopsy of a clivus lesion revealed non-necrotising granulomatous inflammation while fungal cultures and histopathological stains were negative. The patient was diagnosed with widespread sarcoidosis and she was initiated on prednisolone and methotrexate which led to marked clinical and radiological improvement.

Ossified diagnosis: sarcoidosis masquerading as metastatic breast cancer

A 40-year-old woman was referred to the Breast Unit with a solid lump in her right breast. Investigations revealed an invasive lobular carcinoma. The patient underwent a right-sided mastectomy and sentinel lymph node (LN) biopsy, which confirmed axillary LN involvement. The postsurgery staging CT showed unusual enlargement of mediastinal and hilar LN bilaterally. This was consistent with positron emission tomography/CT and MRI, which further established the presence of several bone lesions. Determining the pathology within the LN and bones was pivotal in providing an accurate diagnosis and deciding subsequent management. However, histopathological analysis of the initial endobronchial ultrasound-guided fine-needle aspiration biopsy of mediastinal LN failed to identify definitive metastatic breast cancer cells. The case was extensively discussed in several multidisciplinary team meetings. Collective evidence, including clinical presentation, comparative imaging analysis, and further biopsies confirmed sarcoidosis with bone involvement-mimicking metastatic disease.

Sarcoidosis mimicking metastases in an echinoderm microtubule-associated protein-like 4 anaplastic lymphoma kinase positive non-small-lung cancer patient: A case report

BACKGROUND

Rearrangements of the anaplastic lymphoma kinase (ALK) gene (ALK-positive) represent an oncogenic driver in approximately 3%-5% of non-small-lung cancer (NSCLC) patients. Sarcoidosis is a multisystem disease, and its reported incidence in Asia is 1 or less per 100000 people per year. The co-occurrence of sarcoidosis and ALK-positive NSCLC is rare, and ALK-positive lung cancer is likely to spread quickly. Therefore, the co-occurrence of sarcoidosis is more easily misdiagnosed as metastatic lung cancer by radiological examination.

CASE SUMMARY

A 50-year-old man had a nodule in the left superior lobe, many small nodules in left superior and right lungs, and enlarged bilateral hilar, mediastinal, and right supraclavicular lymph nodes. Computed tomography-guided pulmonary biopsy of the nodule in the left superior lobe revealed echinoderm microtubule-associated protein-like 4 gene-ALK positive NSCLC with concomitant noncaseating granuloma. This patient was treated with crizotinib. Thirty days later, a chest computed tomography scan revealed a dramatic decrease in the size of the left superior lobe nodule; however, the lesions in the right lung progressed. The right supraclavicular lymph nodes showed granulomas, and no tumor cells were identified in the specimens. The angiotensin-converting enzyme level was high. After 1 wk of methylprednisolone treatment, a significant response of all lesions was revealed. Following radical resection of the lung cancer, noncaseating granulomas were observed in both lung tissues and lymph nodes, which resulted in a diagnosis of echinoderm microtubule-associated protein-like 4-ALK positive NSCLC accompanied with sarcoidosis.

CONCLUSION

Our experience illustrates that pathological evidence is needed to confirm metastatic disease, especially when some suspected metastatic lesions are negative for malignancy.

Diffuse lesions secondary to sarcoidosis mimicking widespread metastatic breast cancer: A case report

This case of sarcoidosis mimicking metastatic breast cancer serves as a reminder of the need to consider differential diagnoses even when the clinical scenario and imaging findings are highly suggestive of metastases.

Extrapulmonary sarcoidosis in an atypical patient demographic

Although it typically presents with cough and dyspnea due to pulmonary involvement, sarcoidosis is a multisystem granulomatous disease and therefore may present with extrapulmonary manifestations. Cutaneous manifestations are common, while hepatic sarcoidosis is uncommon and osseous manifestations are exceedingly rare. This article describes osseous, hepatic, and cutaneous manifestations due to sarcoidosis. The patient was diagnosed with sarcoidosis, treated with a dynamic hip screw implant with a derotational screw, and discharged on a new medication regimen: vitamin D, calcium supplements, alendronate, methotrexate, and hydroxychloroquine.

Radiographic and Histopathologic Features in Sarcoidosis: A Pictorial Display

Sarcoidosis is a multisystemic granulomatous disorder that can affect virtually any organ. However, pulmonary and thoracic lymph node involvement predominates; abnormalities on chest radiographs are present in 80 to 90% of patients with sarcoidosis. High-resolution computed tomographic (HRCT) scans are superior to chest X-rays in assessing extent of disease, and some CT features may discriminate an active inflammatory component (which may be amenable to therapy) from fibrosis (for which therapy is not indicated). Typical findings on HRCT include micronodules, perilymphatic and bronchocentric distribution, perihilar opacities, and varying degrees of fibrosis. Less common findings on CT include mass-like or alveolar opacities, miliary opacities, mosaic attenuation, honeycomb cysts, and cavitation. With progressive disease, fibrosis, architectural distortion, upper lobe volume loss with hilar retraction, coarse linear bands, cysts, and bullae may be observed. We discuss the salient CT findings in patients with sarcoidosis (with a major focus on pulmonary features) and present classical radiographic and histopathological images of a few extrapulmonary sites.

Biologic Therapies in Sarcoidosis and Uveitis: A Review

Sarcoidosis and uveitis are chronic inflammatory conditions with potentially debilitating effects on quality of life. Steroids form the mainstay standard therapy in both conditions. Biologic agents are considered to be appropriate alternatives for treatment in steroid-refractory sarcoidosis and uveitis due to the role of tumor necrosis factor (TNF) in mediating the inflammatory cascade seen in both conditions. We performed a thorough literature search using PubMed to compare the extent of use, efficacy, and safety profile of individual anti-TNF agents in the management of these conditions. Our review consists of two systematic reviews with meta-analysis, thirteen observational studies, and fifteen case series/reports. Infliximab had the widest range of organ-system usage in extra-pulmonary sarcoidosis but is equivalent to adalimumab in terms of efficacy. In uveitis, adalimumab was found to be the most efficacious agent for maintaining disease remission in adults and children with chronic non-infectious uveitis. Etanercept was neither used widely, nor was it efficacious in the management of either condition. In terms of safety profile, biologic agents were found to be well tolerated and have a similar safety profile. More randomized clinical trials are needed to inform evidence-based use of biologic agents in these conditions.

Osseous manifestations of sarcoidosis

Sarcoidosis is a systemic multisystem inflammatory disease of unknown etiology. The disease is characterized by formation of non-caseating granulomas. The most common presentation is bilateral hilar lymphadenopathy and lung infiltration, but the disease is very heterogeneous, with an unpredictable clinical course. Musculoskeletal manifestations are common. Bone involvement is less frequent, and usually occurs in patients with chronic multisystem course of the disease. They are most commonly found in the phalanges of hands and feet, and are usually bilateral. The skull, long bones, ribs, pelvis, and axial skeleton may also be affected. Osseous involvement may be asymptomatic but in some cases can cause a severe disability. Imaging techniques are important for diagnosis. Radiological investigations revealed sclerotic or destructive lesions (involving also joints), cystic and punched out lesions and cortical abnormalities. Biopsy is required for differential diagnosis with respect to malignancy. Treatment is a part of systemic therapy and is not needed in all cases. Glucocorticoids and TNF-α antagonists are used for management.

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.

18F-FDG PET/CT in bone sarcoidosis: an observational study

OBJECTIVE

Bone sarcoidosis is usually rare. Imaging procedures such as fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) can reveal bone sarcoidosis with better sensitivity than conventional radiography. We aimed to describe bone sarcoidosis involvement detected with ¹⁸F-FDG PET/CT.

METHODS

This was an observational retrospective study of individuals with pulmonary sarcoidosis who underwent ¹⁸F-FDG PET/CT. According to the ATS/ERS/WASOG criteria, sarcoidosis was diagnosed by the presence of clinical and/or imaging features of sarcoidosis and evidence of non-caseating epithelioid granulomas on a biopsy. We assessed clinical and ¹⁸F-FDG PET/CT characteristics.

RESULTS

Data for 85 patients with sarcoidosis (56.5% female, median age 47 [range 21-80] years) were analyzed. The median follow-up was 4 years. Among 56 patients, sarcoidosis occurred in more than three organs. According to ATS/ERS/WASOG criteria, bone sarcoidosis was diagnosed in 12 (14%) patients. The spine was the most commonly affected location (92%, n = 11), followed by the pelvis (67%, n = 8), sternum (33%, n = 4), humerus (25%, n = 3), and fingers (17%, n = 2). Only peripheral adenopathy was associated with bone sarcoidosis (p = 0.04). Seven patients had a ¹⁸F-FDG PET/CT follow-up, all showing a decrease of bone lesions.

CONCLUSION

Bone sarcoidosis occurred in 14% of patients with sarcoidosis, affecting multiple bones and mostly the axial skeleton. ¹⁸F-FDG PET/CT seems a sensitive tool for diagnosis and follow-up of bone sarcoidosis.

TNF inhibitor treating osseous sarcoidosis and dactylitis: case and literature review

A 49-year-old African American male with multiorgan sarcoidosis presented with recurrent episodes of dactylitis and arthritis. Imaging had shown sarcoid osseous involvement of both hands. This would improve temporarily with high-dose corticosteroids but once tapered, he would experience recurrent flares. Despite several different oral immunosuppressant regimens, significant improvement was only observed after the initiation of adalimumab. Not only was adalimumab successful in symptomatic relief, in addition, patient continues to be in remission with no recurrent episodes of dactylitis. Prednisone was successfully tapered from 40 to 3 mg daily. This improvement with TNF inhibitors has been reported with other manifestations of sarcoidosis including pulmonary and ocular involvements. Osseous sarcoidosis is a very rare presentation, and little information regarding treatment with TNF inhibitors is available. TNF inhibitors should be considered as the next-step therapy in resistant cases of osseous sarcoidosis and dactylitis not responding to corticosteroids and traditional immunosuppressant therapy.

Musculoskeletal Manifestations of Sarcoidosis: A Review Article

BACKGROUND

Sarcoidosis is a multisystem inflammatory disease with an etiology that is not clearly understood. Amongst the different organs that may be affected, the lungs are the most common. Musculoskeletal manifestations of the disease are uncommon.

OBJECTIVES

They include arthropathy, bone lesions, or myopathy, all of which may occur as initial symptoms or develop during the course of the disease.

METHODS

Articular involvement my present as arthralgia or arthritis. Skeletal complications usually develop in the chronic state of the disease. Muscular disease is rare and usually asymptomatic. Appropriate imaging modalities including X-ray, MRI, FDG-PET/CT assist in the diagnosis of rheumatic sarcoidosis. However, biopsy is necessary for definite diagnosis.

RESULT AND CONCLUSION

In most cases of musculoskeletal involvement, NSAIDs and corticosteroids are sufficient for symptomatic management. For more resistant cases immunosuppressive drugs (i.e., methotrexate) and TNF- inhibitors are used. Our aim is to review various types of musculoskeletal involvement in sarcoidosis and their existing treatment options.

Osseous Sarcoma: Is Sarcoma the New Emperor of Maladies? Case-Series with Brief Review of the Literature

Sarcoidosis is multisystem disease that has been amusing physicians since its discovery in 1989 by Caesar Boeck. More than 10,000 articles have been published in the literature by far, and each time it affects a new organ. Involvement of bone has been recently discovered and because it is still a rare entity, it is important to focus on the presenting systems and also to be able to differentiate it from other closely related diseases including but not limited to tumor and other infectious processes. We describe two cases of osseous sarcoma in two relatively young but surprisingly asymptomatic patients.

Musculoskeletal and pulmonary outcomes of sarcoidosis after initial presentation of osseous involvement

OBJECTIVE

We aimed to investigate the musculoskeletal and pulmonary outcomes of patients with osseous sarcoidosis.

METHODS

We identified 24 patients with osseous sarcoidosis and at least one year of follow-up after diagnosis (baseline). We collected outcome data at 1-year follow-up and last follow-up. We defined a composite outcome measure; worsening considered as worsening in any of the following 4 components compared to baseline: 1) osseous sarcoidosis symptoms, 2) musculoskeletal imaging of affected bone, 3) chest imaging, or 4) pulmonary function testing (PFT).

RESULTS

A minority of patients had a worsening composite outcome at 1-year (9/24, 38%) and last follow-up (5/24, 21%). When only considering musculoskeletal symptoms and imaging, only 25% (6/24) and 13% (3/24) of patients worsened compared to baseline at 1-year and last follow-up, respectively. Patients with a worsening composite overall outcome tended to be older at baseline than those without the outcome for both 1-year (54.3 years vs. 47.5 years, p=0.11) and last follow-up (55.0 years vs. 48.7 years; p=0.23), although these differences were non-significant. Treatment was not associated with worsening composite overall outcome at 1-year follow-up (p=0.40), but was significantly associated with decreased risk for worsening at last follow-up (p=0.05).

CONCLUSIONS

In this retrospective cohort study of osseous sarcoidosis, most patients had a favorable outcome according to symptoms, musculoskeletal/chest imaging, and PFTs, even though only a minority were treated with glucocorticoids or DMARDs. These results suggest that the natural history of osseous sarcoidosis is often benign, although some patients experience clinical progression.

Radiologic Manifestations of Musculoskeletal Sarcoidosis

PURPOSE OF REVIEW

The purpose of this review article is to present the spectrum of abnormalities and multi-modality imaging evaluations in patients with musculoskeletal sarcoidosis.

RECENT FINDINGS

The articular manifestations of sarcoidosis are difficult to distinguish from those of the other inflammatory and degenerative arthropathies, and the muscular lesions in sarcoidosis are generally clinically silent and therefore often missed. Magnetic resonance imaging has shown these manifestations to be very common in active sarcoidosis, and should thus be included in the screening if musculoskeletal sarcoidosis is suspected. The clinician should consider magnetic resonance imaging for the evaluation of patients with sarcoidosis who have unexplained osteoarticular complaints if standard radiographs are negative. Furthermore, radiologists should include sarcoidosis in the differential diagnosis of musculoskeletal disease detected at magnetic resonance imaging in the appropriate clinical setting.

A review of the musculoskeletal manifestations of sarcoidosis

Sarcoidosis is a systemic disease of unknown aetiology that is characterized by granulomatous inflammation that can develop in almost any organ system. Musculoskeletal manifestations are seen in up to one-third of patients, ranging from arthralgia through to widespread destructive bone lesions. Inflammatory tendon lesions and periarticular swelling are more common than true joint synovitis. Despite advances in our understanding of the pathophysiology of the disease, diagnosis remains challenging. Definitive diagnosis, irrespective of organ site involvement, hinges on histological confirmation of non-caseating granuloma combined with an appropriate clinical syndrome. Musculoskeletal involvement usually develops early in the disease course. Imaging modalities, particularly fluorodeoxyglucose PET, are helpful in delineating the extent of involvement and measuring disease activity. Bone involvement may only become apparent following isotope imaging. Corticosteroids remain the cornerstone of treatment. MTX is the steroid-sparing agent of choice unless there is renal involvement. Biologic therapies are sometimes used in severe disease, although the evidence base for efficacy is inconsistent.

Paroxysmal cough and left sacroiliac joint pain in a 50-year-old Caucasian man

A 50-year-old Caucasian man who was a lifelong nonsmoker presented with a 3-year history of paroxysmal dry cough, fatigue, nonspecific myalgias, muscle weakness of the lower extremities and left sacroiliac joint pain. Initially, he was reviewed by a pulmonologist and subsequently he was referred to the Dept of Thoracic Medicine (Heraklion University Hospital, Heraklion, Greece) for further investigation. His medical history was remarkable for the presence of arterial hypertension on treatment with amlodipine and irbesartan.

Can you diagnose this patient with pulmonary symptoms, thoracic and laboratory test abnormalities and sacroiliac joint pain?http://ow.ly/LPyy30kaViz

Orthopaedic Considerations in the Management of Skeletal Sarcoidosis

Advanced imaging has demonstrated that musculoskeletal manifestations of systemic sarcoidosis are more common than previously thought. A definitive strategy for the management of osseous sarcoidosis has not been defined. Some lesions resolve spontaneously, and no systemic medication for sarcoidosis consistently resolves lesions. The orthopaedic surgeon treating patients with musculoskeletal sarcoidosis must make an appropriate diagnosis of bony lesions, seek multidisciplinary input from specialists in pulmonology and rheumatology regarding systemic treatment, and decide when surgery is necessary to prevent dysfunction.

Emergency Radiotherapy for Spinal Cord Compression due to Bone Sarcoidosis

Sarcoidosis is an inflammatory granulomatous disease that is systemic, but bone involvement is uncommon. A 68-year-old man was referred to our hospital complaining of right shoulder pain with numbness. Computed tomography revealed systemic lymphadenopathy and multiple bone lesions. Because malignant lymphoma with a mass lesion protruding into the vertebral canal was considered, he underwent urgent radiotherapy. Thereafter, a needle biopsy of the left parasternal node was performed and showed epithelioid granulomas, confirming a diagnosis of sarcoidosis. Since his neurologic symptoms improved, the patient was not given systemic corticosteroids. Radiotherapy may be useful for local control of bone sarcoidosis.

An erosive lesion in the orbital apex as the presenting sign of sarcoidosis

Sarcoidosis is an autoimmune granulomatous disease that can affect any organ system in the body. Ocular and orbital manifestations are relatively common. Osseous involvement is rare and usually involves bones of the appendicular skeleton. We present an unusual case of an erosive sarcoid granuloma in a 48-year-old woman that involved the orbital apex. This case highlights diagnosis, treatment, and the importance of full systemic workup to determine the extent of the disease.

An Unusual Orthopaedic Disease: Sarcoidosis-A Case Report

Sarcoidosis is an idiopathic, noncaseating granulomatous disorder with wide systemic involvement. It is encountered widely around the world and it affects both sexes, all the races in all age groups. Lungs, eyes, and skin are the organs most commonly affected. Constitutional features such as weight loss, fatigue, and myalgia are the most common symptoms. Bone involvement, which is very rare, was reported as present in 3 to 13% of effected cases, and it is most commonly seen in hands and feet, compared with long bone involvement, which is extremely rare. We hereby present a case with a diagnosis of sarcoidosis and multiple bone involvement emphasizing the importance of differential diagnosis.

A rare presentation of histologically proven sarcoidosis of the knee: A case report and brief review of the literature

We here report a patient with histologically proven sarcoidosis of the knee, a rare localization of sarcoidosis, which usually presents itself as a pulmonary disease. Case reports of radiological images that suggest osseous sarcoidosis of the appendicular skeleton are not so rare, however few are histologically proven. Since in our patient MRI could not distinguish between sarcoidosis and another (possibly malignant) disease, histological proof was obtained through a CT-guided biopsy. Imaging and treatment guidelines for extrapulmonary sarcoidosis are inexistent, due to lack of randomized trials.

Benign Bone Conditions That May Be FDG-avid and Mimic Malignancy

Positron emission tomography with the radiotracer ¹⁸F-fluoro-2-deoxy-d-glucose (FDG) plays an important role in the evaluation of bone pathology. However, FDG is not a cancer-specific agent, and knowledge of the differential diagnosis of benign FDG-avid bone alterations that may resemble malignancy is important for correct patient management, including the avoidance of unnecessary additional invasive tests such as bone biopsy. This review summarizes and illustrates the spectrum of benign bone conditions that may be FDG-avid and mimic malignancy, including osteomyelitis, bone lesions due to benign systemic diseases (Brown tumor, Erdheim-Chester disease, Gaucher disease, gout and other types of arthritis, Langerhans cell histiocytosis, and sarcoidosis), benign primary bone lesions (bone cysts, chondroblastoma, chondromyxoid fibroma, desmoplastic fibroma, enchondroma, giant cell tumor and granuloma, hemangioma, nonossifying fibroma, and osteoid osteoma and osteoblastoma), and a group of miscellaneous benign bone conditions (post bone marrow biopsy or harvest status, bone marrow hyperplasia, fibrous dysplasia, fractures, osteonecrosis, Paget disease of bone, particle disease, and Schmorl nodes). Several ancillary clinical and imaging findings may be helpful in discriminating benign from malignant FDG-avid bone lesions. However, this distinction is sometimes difficult or even impossible, and tissue acquisition will be required to establish the final diagnosis.

Diffuse phalangeal signal abnormality on magnetic resonance imaging: phalangeal microgeodic disease

BACKGROUND

Phalangeal microgeodic disease is a rare and benign self-limited condition involving the phalanges, often in the setting of cold exposure, with characteristic MR imaging abnormalities. Radiographic case descriptions are predominantly from Asia and Europe, with only seven cases using MR to characterize phalangeal microgeodic disease.

OBJECTIVE

In this study we describe the MR imaging appearance of unusual and striking phalangeal signal abnormality compatible with phalangeal microgeodic disease at our institution in North America.

MATERIALS AND METHODS

We retrospectively reviewed cases presenting at our institution with unusual or unexplained phalangeal signal abnormalities between 2001 and 2014. We reviewed the MR imaging appearances in conjunction with radiographs and any other available imaging investigations.

RESULTS

Of 189 examinations reviewed during the study period, 8 imaging studies in 6 patients met the study inclusion criteria. Signal abnormality was present in 57 of 112 phalanges (51%), frequently involving the distal phalanges (70%, 28 of 40), followed by the middle phalanges (56%, 18 of 32) and the proximal phalanges (28%, 11 of 40). The pattern of involvement was most commonly diaphysis (38%), followed by metaphysis (32%) and epiphysis (30%). The extent of MR signal abnormality was greater than that suspected based on clinical presentation or on radiographs.

CONCLUSION

The presence of unexplained diffuse characteristic marrow involvement of multiple painful phalanges on MR images, often in the setting of cold exposure, should raise the possibility of phalangeal microgeodic disease. Consideration of this diagnosis based on MR findings would lead to a more conservative management and avoid unnecessary invasive diagnostic procedures.

Clinical characteristics of patients with bone sarcoidosis

OBJECTIVE

To assess the clinical features, diagnosis, and treatment of bone sarcoidosis in the United States.

METHODS

Patients with bone sarcoidosis were identified and matched to sarcoidosis patients based on race, gender, and age. Detailed characteristics were obtained by medical record review.

RESULTS

A total of 64 patients with bone sarcoidosis were enrolled in this study. The female:male ratio was 1.46:1 and the white:black ratio was 3:1. Thirty-eight (59.4%) of 64 patients had bone symptoms. Compared to matched cases, bone sarcoidosis patients have more multi-organ involvement and higher incidence with liver, spleen, and extrathoracic lymph node involvement than controls (P < 0.05). Spine was the most commonly affected bone in 44 (68.8%) of patients, followed by pelvis (35.9%), and hands (15.6%). MRI and PET/CT scan was the common imaging technology, which performed in 36 patients and 32 patients, respectively, and with 97.2% and 93.8% positive bone uptake. Laboratory test indicated anemia was more common in bone sarcoidosis group than controls (P = 0.044). Infliximab was more commonly used in bone sarcoidosis patients than controls (P = 0.009).

CONCLUSION

Bone sarcoidosis was associated with multi-organs affection, and high frequency of liver, spleen, or extrathoracic lymph node involvement. Infliximab should be considered in those patients with aggressive and refractory bone sarcoidosis.

Intrascrotal and osseous sarcoidosis mimicking intrascrotal organ cancer and bony metastasis

We report a case of sarcoidosis with concomitant epididymis, testes, and phalanxes involvement mimicking intrascrotal organ cancer and metastatic bony disease. A 23-year-old man developed blurred vision and hyperemia of the left eye, and was diagnosed as having left iritis. A chest computed tomography scan detected bilateral hilar lymphadenopathy and lung nodular shadows. A transbronchial lung biopsy revealed a non-caseating granuloma and he was diagnosed with sarcoidosis. One year after the onset of his eye symptoms, he noticed enlargement of his right scrotum. Magnetic resonance imaging detected lesions of the right epididymis, bilateral testes, and bilateral phalanxes. A technetium-99m scintigram revealed a high accumulation in the bilateral bones of extremities. These radiological findings mimicked intrascrotal organ cancer and metastatic bony disease. Pathologic evaluation following the right epididymectomy revealed non-caseating granulomas compatible with sarcoidosis. Three and half years after the appearance of intrascrotal and bony lesions, they improved spontaneously. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 373-376).

Paraneoplastic Sarcoidosis in Multiple Myeloma

Sarcoidosis predominantly affects the lungs, intrathoracic lymph nodes, and eyes; it less frequently affects the musculoskeletal system. We herein report a case of paraneoplastic sarcoidosis in a patient presenting with multiple myeloma. The patient developed ocular sarcoidosis and showed an increased ¹⁸F-fluorodeoxyglucose uptake in the mediastinal lymph nodes and vertebral column. A lymph node specimen showed the histological features of sarcoidosis, while an examination of the vertebral tumor revealed myeloma. Although the simultaneous occurrence of sarcoidosis and myeloma is extremely rare, our case indicates the importance of exculing any underlying malignancies before establishing a diagnosis of skeletal sarcoidosis when bone lesions are observed at unusual sites.

Fulminant musculoskeletal and neurologic sarcoidosis: case report and literature update

We report a case of fulminant sarcoidosis in a 28-year-old man presenting with skin nodules, multifocal small and large joint arthralgias, and blurred vision. Characteristic bone, soft tissue, articular, and CNS findings were evident on multimodality imaging. Bony abnormalities included near-complete destruction of a distal phalanx, "lace-like" lucent lesions, erosive arthritis, lytic lesions with and without sclerotic margins, and bone marrow replacement visible only on MRI. The extent of bony disease at time of presentation was unusual. We review the widely varying reported prevalence of imaging findings of bony sarcoidosis in the literature, and discuss reasons for this variability. We found that musculoskeletal findings at US and MRI were less specific than radiographic and CT findings, but were useful in quantifying extent of disease.

Osteolysis of unknown origin: a case report

Background

Sarcoidosis is a granulomatous disease that may affect any organ of the body. The most frequent loci of manifestation are the lungs. However, there are individual cases where bones are affected. The literature describes cases in which swelling or fistula were the first findings of a bone lesion. This is the first case reporting an osteolysis in both angles of the mandibles which led to the diagnosis of sarcoidosis with multi-organ involvement.

Case presentation

The authors present a 74 years old European female patient without previous diagnosis of sarcoidosis who presented with pain in the area of the jaw angles. There were no further clinical symptoms. Bone biopsy following radiological investigation demonstrated non-caseating granulomas consistent with sarcoidosis of the bone. Further evaluation confirmed multi-organ disease with involvement of lungs, intrathoracic lymph nodes, and the central nervous system.

Conclusion

This case report shows that diagnosis of a severe disease can be missed if systematic clinical signs are not given. Furthermore, an accurate anamnesis and examination is required to receive an early diagnosis which often needs an interdisciplinary approach.

Corticosteroids in Sarcoidosis

Corticosteroids are the drug of choice for the treatment of sarcoidosis. Because the natural course of sarcoidosis may be self-limiting and/or cause no long-term harm, treatment is not mandatory. Corticosteroids are usually effective for all forms of sarcoidosis, and they work quickly. However, because of the potential toxicities of corticosteroids, alternative medications often need to be considered. Efforts should be made to minimize the corticosteroid dose while keeping the risk of toxicity as low as possible. This article outlines the indications for corticosteroid therapy for sarcoidosis, discusses various dosing regimens, and suggests when alternative corticosteroid agents should be considered.

Sarcoidosis: a rheumatologist's perspective

Sarcoidosis is a systemic disorder of unknown etiology, which may involve various tissues and organs and is characterized by a noncaseating granuloma reaction. While pathogenesis is not yet clear, cellular immune system activation and nonspecific inflammatory response occur secondarily to several genetic and environmental factors. T helper 1-cells and macrophage-derived pro-inflammatory cytokines stimulate the inflammatory cascade and formation of granuloma occurs as a result of tissue permeability, cell influx, and local cell proliferation. The different prevalence, clinical results, and disease course observed in different races and ethnic groups, is an indicator of the heterogeneous nature of the disease. Sarcoidosis may mimic and/or may occur concomitantly with numerous primary rheumatic diseases. This disease most commonly presents with bilateral hilar lymphadenopathy, pulmonary infiltrations, and skin and eye lesions. Locomotor system involvement is observed at a range of 15% and 25%. Two major joint involvements have been described: acute and chronic form. The most common form, the acute form, may be the first sign of sarcoidosis and present with arthralgia, arthritis, or periarthritis. Chronic sarcoid arthritis is usually associated with pulmonary parenchymal disease or other organ involvement and occurs rarely. While asymptomatic muscular involvement is reported between 25% and 75%, symptomatic muscular involvement is very rare. Symptomatic myopathy may present as three different types: chronic myopathy, palpable nodular myositis, or acute myositis. Even if rare, 2-5% of cases may exhibit osseous involvement and it is frequently associated with lupus pernio, chronic uveitis, and multisystemic disease. Sarcoidosis was reported together with different rheumatologic diseases. There are studies showing that sarcoidosis may mimic the clinical and laboratory findings of these disorders. Nonsteroidal anti-inflammatory drugs and corticosteroids are used for treating the symptoms of rheumatologic findings. In patients who are unresponsive to corticosteroids, immunosuppressive and anti-tumor necrosis factor alpha drugs may be used. In this review, the incidence of rheumatologic symptoms, the clinical findings, and the treatment of rheumatologic manifestations of sarcoidosis are discussed.

A case of acute septic arthritis hip caused by Brucella melitensis in an adolescent child

Brucella is among the most common zoonotic diseases affecting humans. Although musculoskeletal involvement is seen in a large proportion of patients, the disease is often diagnosed late or misdiagnosed due to its subtle nature and rarity, and lack of awareness among clinicians. In this report, a 12-year-old girl was diagnosed with acute septic arthritis of the hip based on clinico-radiological features, and managed with standard treatment, including arthrotomy. However, the child did not respond to the treatment. Based on the histopathology and local endemicity, Brucella was suspected, and confirmed after serological testing. The child subsequently responded to treatment and, at latest follow-up at 1 year, had a full painless range of motion, with no relapse.