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Extrapulmonary Sarcoidosis Presenting With Rare Axial Bone Lytic Lesions Mimicking Bone Metastasis FREE TO VIEW

Samer AlSamman, MD; Soumya Parimi, MD; Mohd Amer AlSamman, MD
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Good Samaritan Hospital, Cincinnati, OH

Chest. 2014;146(4_MeetingAbstracts):455A. doi:10.1378/chest.1988071
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SESSION TITLE: Miscellaneous Student/Resident Case Report Posters I

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Sarcoidosis is a granulomatous disease that typically occurs in lungs but can present with extrapulmonary manifestations. Skeletal involvement is rare, and usually associated with skin manifestations. This is a rare case of extrapulmonary sarcoidosis with axial bone disease and no lung involvement.

CASE PRESENTATION: A 60 year old Caucasian woman (non-smoker) presented with several months of bilateral hip, thigh and back pain, for which she underwent steroid injections with no improvement. On a left hip X-ray, bilateral bony lucencies concerning for lytic lesions were noted. A bone scan showed no concerning lesions, however, a pelvic MRI was obtained and noted bilateral bony lytic lesions throughout the hips and femurs. She has recent normal screening mammogram and colonoscopy, as well as protein electrophoresis. There was no history of malignancy, and no masses, lymphadenopathy or skin lesions were found on physical exam. A repeat mammogram was normal as well as hemoglobin, calcium, and creatinine She was evaluated by an oncologist who suspected malignancy. A chest, abdomen and pelvis CT scan revealed numerous small lytic bone lesions scattered throughout the thoracic and lumbar spine, pelvis, and femurs, as well a single slightly enlarged pretracheal node. Lung parenchyma was normal. She underwent a CT guided biopsy of one of the hip lesions, and the result showed non caseating granulomas in the bone marrow with associated bone destruction, but no malignancy. AFB and GMS stains were negative. On further evaluation, she revealed that four years ago she had uveitis following an episode of shingles. She was treated with steroids and methotrexate for over a year, and she has had no recurrence since. Six months prior to this presentation, a LBBB was found on ECG and a cardiac evaluation showed a mild cardiomyopathy of unclear etiology. Further evaluation showed normal PFT. She was started on prednisone treatment at 0.5mg/kg/day.

DISCUSSION: This patient presented with a unique constellation of axial bone involvement, conductive heart defect and uveitis, in the absence of skin and lung involvement. All these findings were attributed to Sarcoidosis. Bone is involved in 5 (1-13)% of patients, almost all of them have peripheral small bone lesions in the hands and feet, however, every bone can be affected. Axial (spinal) involvement is rare and seldom reported. Lesions can be cystic, lytic or sclerotic, and mimic bone metastasis and myeloma on imaging. Half of these patients are asymptomatic, but pain and weakness may occur.

CONCLUSIONS: The skeletal system can be involved in extrpulmonary sarcoidosis, though axial lesions are rare. Bone lesion biopsy is recommended to rule out malignancy. Corticosteroids are the first line therapy, but other options like TNF-α inhibitors can be used in refractory cases.

Reference #1: Sweiss NJ, et al. Rheumatologic manifestations of sarcoidosis. Semin Respir Crit Care Med. 2010 Aug;31(4):463-73. doi: 10.1055/s-0030-1262214

DISCLOSURE: The following authors have nothing to disclose: Samer AlSamman, Soumya Parimi, Mohd Amer AlSamman

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