Pulmonary Manifestations of Systemic Disease: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease I |

The Paradox of Methotrexate: A Case of Bone Marrow Sarcoidosis FREE TO VIEW

Umair Nazir, MD; Khansa Ahmad, MD; Srinath Sriram, MD
Author and Funding Information

Weiss Memorial Hospital, Chicago, IL

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1081A. doi:10.1016/j.chest.2016.08.1188
Text Size: A A A
Published online

SESSION TITLE: Student/Resident Case Report Poster - Pulmonary Manifestations of Systemic Disease I

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Sarcoidosis is a multi-organ system disorder of unclear etiology, first described in 1899 as “Multiple benign sarcoid” for its resemblance to sarcoma, characterized by epithelioid giant cell clusters forming granulomas.[1]Female preponderance across all racial ethnic backgrounds mostly between 30-50 years is noted. [2] Bone marrow involvement is extremely rare, therefore identification, diagnosis and treatment can be a challenge. We present a case of bone marrow sarcoidosis with pancytopenia & management with methotrexate.

CASE PRESENTATION: 47 year old female with a medical history of valvular cardiomyopathy, chronic kidney disease and hypothyroidism presented with complaints of weakness and falls. She was found to have hypercalcemia and pancytopenia. Parathyroid hormone, Vitamin D, SPEP and UPEP, were within normal limits. C-telopeptide and ACE levels were elevated indicating increased bone turnover and possibility of sarcoidosis. Chest Xray and CT scan were unremarkable for pulmonary involvement or hilar lymphadenopathy. Bronchoscopy with BAL was performed. Bone scan was unremarkable for osseous metastatic disease. Bone marrow biopsy revealed hypercellularity and multiple non-necrotizing epithelioid granulomas. Fungal infection and tuberculosis was ruled out by negative PAS, GMS, mucicarmine and AFB stains. The pancytopenia, elevated ACE level, elevated CD4/CD8 ratio on BAL and non necrotizing granulomas in bone marrow were all supportive of sarcoidosis. Initially 60 mg of prednisone was started which resulted in resolution of pancytopenia, fevers and lethargy. However, when the prednisone was reduced to 40 mg, her symptoms relapsed and 60 mg of prednisone was restarted with no improvement. After discussion, Methotrexate 12.5 mg weekly was initiated with close follow up. Patient has since remained stable. Her pancytopenia has improved, ACE level has normalized and febrile episodes have resolved.

DISCUSSION: Bone marrow involvement in sarcoidosis is uncommon. One case series reported 10% of patients had granulomas in their bone marrow biopsies (3). Methotrexate is a widely used treatment for sarcoid, but a potential adverse effect is bone marrow suppression (1). There are limited cases of using methotrexate specifically for sarcoid induced pancytopenia. This case shows that methotrexate can be a safe and effective option for treatment.

CONCLUSIONS: Diagnosis of sarcoidosis requires a stepwise approach, with histopathological confirmation and exclusion of fungal and tuberculous infection and malignancy. Sarcoidosis infiltrating bone marrow is rare and resultant pancytopenia can be treated successfully with methotrexate.

Reference #1: Sarcoidosis Michael C. Iannuzzi et al. N Engl J Med 2007; 357:2153-2165November 22, 2007DOI: 10.1056/NEJMra071714

Reference #2: Racial differences in sarcoidosis incidence: a 5-year study in a health maintenance organization. Rybicki BA et al.

Reference #3: Bone marrow involvement in sarcoidosis: an analysis of 50 bone marrow samples. Yanardağ H et al.

DISCLOSURE: The following authors have nothing to disclose: Umair Nazir, Khansa Ahmad, Srinath Sriram

No Product/Research Disclosure Information




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
Childhood sarcoidosis: Louisiana experience. Clin Rheumatol 2016;35(7):1879-84.
Bone and bone marrow involvement in sarcoidosis. Rheumatol Int 2015;35(11):1917-24.
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543