The Sudden Development of Multi-Organ Lesions in a Patient With Pulmonary Sarcoidosis: A Case Report

Abstract

Introduction. Sarcoidosis is a systemic granulomatous inflammatory disease that can involve almost any organ system in the human body. It most frequently presents with pulmonary infiltrates, hilar lymphadenopathy, and skin lesions. Clinical and subclinical involvement of other organ systems is not uncommon. However, the simultaneous development of clinically apparent multisystem sarcoidosis is very rare. Case Description. This 44-year-old Caucasian man presented to an outpatient clinic with a 2-month history of fatigue, night sweats, weight loss, loss of appetite, and mild abdominal discomfort. Initial laboratory finding showed elevated liver enzymes. Imaging studies revealed cirrhotic liver with steatosis, few enhancing hepatic masses, and multiple enlarged periaortic and portocaval lymph nodes. Liver biopsy revealed scattered necrotizing granulomatous hepatitis. Positron emission tomography scan showed extensive hepatic uptake, diffuse lymphadenopathy, as well as numerous fluorodeoxyglucose-avid osseous lesions. After extensive workup to rule out malignancy and infectious etiologies, a diagnosis of diffuse multi-organ sarcoidosis was made. He was ultimately treated with methotrexate and steroids, resulting in marked improvement in symptoms and liver function, with stable disease on repeat imaging. Conclusion. Diffuse multi-organ sarcoidosis is often associated with widespread lymphadenopathy and osseous lesions, which appear indistinguishable from malignancy on imaging. The angiotensin converting enzyme levels and inflammatory markers may be normal. Clinicians should be aware of the possibility of diffuse systemic sarcoidosis in any patient with a remote sarcoidosis history and the simultaneous development of multi-organ-related symptoms.

Multisystemic Sarcoidosis Presenting with Widespread Vertebral Osseous and Visceral Lesions Masquerading as Metastatic Disease: A Case Report and Literature Review

“…Vertebral sarcoidosis is a rare occurrence [ 4 , 5 , 8 , 9 ] and tends to exhibit a peculiar involvement to the thoracic and upper lumbar vertebral bodies (as observed in our case), with much less frequent affection of the cervical vertebrae [ 5 , 9 ]. It typically presents with persistent back pain [ 1 , 4 ]. Vertebral compression fractures and neurological sequalae are unusual complications, but they have been reported [ 1 , 4 , 5 , 9 ].…”

“…Sarcoidosis predominantly affects the lungs, skin, and lymph nodes, and the subclinical involvement of other organ systems is not uncommon [ 1 – 5 ]. However, presentation with a clinically apparent multisystem disease with disseminated vertebral and visceral lesions, as reported in our patient, is rare, as this pattern of presentation has been reported in only a handful of cases [ 4 – 7 ]. An interesting case of a 59-year-old woman who had a clinically silent and incidentally diagnosed multisystemic sarcoidosis with extensive osseous, hepatic, and pulmonary lesions was described by Mehrotra et al [ 8 ]; the patient had presented with a facial nerve palsy, which complicated a viral infection, but further diagnostic work-up revealed a widespread sarcoidosis, and the patient was deemed ineligible for steroids treatment as she was utterly asymptomatic from the perspective of sarcoidosis.…”

“…In fact, it is quite challenging for clinicians to suspect a disseminated extrapulmonary sarcoidosis, as its clinical features are rather diverse and largely nonspecific, as demonstrated in our case [ 4 – 7 ], and the diagnosis warrants the exclusion of other causes of chronic granulomatous diseases, including infections, such as tuberculosis and histoplasmosis, systemic autoimmune diseases, such as Crohn disease, and metastatic cancers, including lymphomas and multiple myeloma [ 7 ]. The latter are great mimickers of multisystemic sarcoidosis with vertebral involvement, and similar cases of osseous sarcoidosis were initially thought to be or misdiagnosed as meta-static bone diseases, owing to the extreme clinical and radiological similarities between the 2 disease entities [ 4 , 5 , 8 – 10 ].…”

“…It typically presents with persistent back pain [ 1 , 4 ]. Vertebral compression fractures and neurological sequalae are unusual complications, but they have been reported [ 1 , 4 , 5 , 9 ]. MRI imaging in vertebral sarcoidosis demonstrates low signals on T1-weighted images and hyper-intense signals on T2-weighted images owing to a granulomatous infiltration of the marrow [ 5 , 9 ].…”

“…Other radiological findings include mixed osteolytic and osteosclerotic lesions, and rarely, predominant osteosclerotic lesions simulating osteoblastic metastases [ 5 ]. It is worth mentioning that positron emission tomography with 18-fluorodeoxyglucose imaging (FDG) might not be very differentiating between the vertebral sarcoidosis and metastatic cancers [ 5 ], as FDG also accumulates within the activated macrophages and epithelioid cells in active granulomatous inflammation [ 5 ]; therefore, only the bone biopsy is considered the criterion standard to prove sarcoidosis and to exclude metastatic cancers or multiple myeloma [ 4 , 5 ].…”