Rare case of multisystem sarcoidosis

Abstract

Sarcoidosis is a multisystem disorder of unknown cause, characterised pathologically by granulomas and primarily affecting the lung and lymphatic system of the body. It has been termed the 'great pretender' due to its ability to mimic other diseases. In this article we describe a case of sarcoidosis with simultaneous rare manifestations of extrathoracic disease (thyroid, osseous and renal). It highlights the enigmatic nature of sarcoidosis and the diagnostic challenge it can pose to clinicians. A multidisciplinary approach to both diagnosis and management between endocrinology, nephrology, neurosurgical, rheumatological and respiratory teams was paramount for effective clinical improvement.

Keywords: acute renal failure; interstitial lung disease; musculoskeletal syndromes.

Figure 1

(A) MRI of whole spine, sagittal plane: multiple marrow lesions involving the vertebral bodies and posterior elements of various parts of the spine with intense oedematous/inflammatory changes of the surrounding soft tissue were present. Lesion involving the vertebral body of T10 vertebra body bulged underneath the posterior longitudinal ligament without breaching it (block arrow). Two large lesions involving the S1 segment were also present (dashed arrow). (B) MRI of whole spine, coronal plane: two large sacral lesions demonstrated (arrows). (Ci, Cii) High-resolution CT of chest: mildly enlarged bilateral hilar and central mediastinal lymph nodes with calcification (dashed arrow). Within the lung parenchyma scattered stellate end nodular opacities were present (block arrow). (D) Thyroid ultrasound image: the thyroid gland was grossly abnormal. The majority of the gland was hypoechoic with some anterior lobulation in keeping with diffuse infiltration. Some normal left lobe parenchyma. No increased vascularity was seen. (E) Thyroid fine needle aspiration showing a tight aggregate of epithelioid histiocytes forming a granuloma (arrow). Images were taken at ×100 magnification. (F) Bone biopsy demonstrating a well formed sarcoidal granuloma. The background shows prominent chronic inflammatory infiltrate including lymphocytes and plasma cells. Images were taken at ×100 magnification (arrow).