Sarcoidosis of bone is infrequent and vertebral involvement is rare. We present a unique case of vertebral sarcoidosis that responded to hydroxychloroquine and low dose steroids. This is most likely the first reported case of vertebral sarcoidosis treated successfully with hydroxychloroquine and prednisone.
A 58-year-old Caucasian female developed severe back pain. Physical examination was unremarkable. A bone scan showed multiple focal uptakes in the lower thoracic and upper lumbar (L) vertebrae. Magnetic resonance imaging (MRI) of her spine revealed multiple areas of hypo-intensity on T1 weighted images within the lumbar vertebral bodies. A chest computed tomogram (CT) revealed two small (<7mm) lung nodules. Her Gallium-67 imaging scan did not show any focal uptake. Her serum angiotensin converting enzyme (39u/l) and serum calcium (10.7mg/dl) were normal. A CT guided biopsy of the L1 pedicle revealed non-caseating granulomas with no tumor cells. Acid fast and fungal stains and cultures were negative. Hydroxychloroquine 200mg twice a day and Prednisone 20mg daily were started. Serial MRI showed significant improvement of the lumbar and thoracic vertebral sarcoid lesions over the following two years. Prednsione was tapered after four months and was discontinued at 16 months. Hydroxychloroquine was continued for two years.DISCUSSION: Osseous sarcoid is reported in 3% to 13% of cases with multi-system sarcoidosis (1). Small bones of the hand and the feet are most commonly affected and vertebral involvement is very rare (12). In such cases diagnosis is fairly straightforward. The diagnosis may remain obscure when bone involvement occurs in the absence of other manifestations of sarcoidosis. On presentation, our patient did not have active pulmonary sarcoidosis. She was reluctant to start high dose steroids, so a combination of hydroxychloroquine with prednisone was given. Hydroxychloroquine may inhibit processing of the putative antigen by macrophages and the production of TNF-alpha and IL-6, thereby modifying the initial steps in the pathogenesis of the disease process (678). It reduces hyperglycemia and is helpful in patients with steroid induced hyperglycemia (6). Hydroxychloroquine alone or in combination with prednisone is effective in neurosarcoidosis, hypercalcemia and skin lesions of sarcoid (78). To our knowledge, this is the first reported case in English literature of vertebral sarcoidosis successfully treated with combination of hydroxychloroquine and low dose steroids.
We present a case of MRI resolution of vertebral sarcoidosis with hydroxychloroquine and low dose prednisone. Less aggressive regimen may be effective in treatment of vertebral sarcoid.
S.U. Islam, None.