Rheumatologic Manifestations of Sarcoidosis

Nadera J. Sweiss, M.D.; Karen Patterson, M.D.; Ray Sawaqed, M.D.; Umair Jabbar; Peter Korsten, M.D.; Kyle Hogarth, M.D.; Robert Wollman, M.D.; Joe G.N. Garcia, M.D.; Timothy B. Niewold, M.D.; Robert P. Baughman, M.D.

Disclosures

Semin Respir Crit Care Med. 2010;31(4):463-473. 

In This Article

Case Studies

Case 1

A 47-year-old African American woman with long-standing biopsy-proven sarcoidosis, presented with progressive arthritis involving pain in multiple finger joints and left shoulder, dyspnea on exertion, and prior hemoptysis. The disease was complicated by stage IV fibrocavitary lung disease, lung mycetoma, and traction bronchiectasis, which required antifungal therapy. The arthritis was minimally responsive to NSAIDs, methotrexate, and low-dose prednisone (4 mg). Rheumatologic examination showed synovitis and erythemas of the distal interpharyngeal (DIP) joints and the proximal interpharyngeal (PIP) joints bilaterally. Dystrophic nail changes were also noted. Photographs of the same hands are shown in Fig. 4 and reveal diffuse swelling involving the PIP and DIP joints. Erythema is also noted at both joints; at the DIP, indicating that the sarcoid arthritis is acute, and at the PIP, suggesting that the arthritis is chronic. Dystrophic nail changes are also noted, and there is no evidence of pitting. Hand radiographs shown in Fig. 5 reveal osseous erosions bilaterally. Lacy reticular patterns, which are characteristic of sarcoidosis and acroosteolysis of distal phalanx tufts are shown as well as granulomatous erosions (Fig. 5). Methylprednisolone at a dose of 8 mg/day failed to control the signs and symptoms of arthritis; injectable methotrexate at a dose of 10 mg/week was added due to poor tolerance to oral methotrexate. The combination of methylprednisone and methotrexate resulted in partial improvement of the arthritis signs and symptoms. Hydroxychloroquine at a dose of 400 mg daily was added. Anti-TNF-α therapy was not initiated given the active fungal infection.

Figure 4.

Hand photograph shows (A) proximal interpharyngeal (PIP) joint swelling and erythema, (B) distal interpharyngeal (DIP) joint swelling and erythema, and (C) dystrophic nail changes, without evidence of pitting.

Figure 5.

Hand x-ray from patient in Figure 4 reveals osseous erosions bilaterally. Big circle: Lacy reticular pattern characteristic of sarcoidosis—fifth digit and soft tissue swelling. Small circles: Acroosteolysis of distal phalanx tufts. Long arrow: Punched-out granuloma neck proximal phalanx of ring finger. Short arrows: Granulomatous erosion.

Case 2

A 42-year-old healthy Caucasian man presented with several years' history of back pain. Spine radiographs showed a pathological L4 compression fracture as well as multiple vertebral hypodense lesions as well as iliac crest and humorous lesions (Fig. 6). A diagnosis of sarcoidosis was made after a thorough workup for malignancy. Open bone biopsy from the left humerus and the left iliac crest showed noncaseating granulomas, acid-fast bacilli stains, and fungal stains; cultures were negative. The disease was complicated by osteoporosis that was treated with oral bisphosphonates, but there was no evidence of metabolic bone disease, and serum calcium was within normal limits. There was no evidence of lung, hepatic, cardiac, or neurosarcoidosis. Oral prednisone at a dose of 10 mg/day for a few months resulted in partial pain control. His symptoms returned when the prednisone dose was tapered to 5 mg/day. Oral prednisone was switched to methyl-prednisolone at a dose of 4 mg/day with significant symptomatic improvement. Repeat spine images with radiographs and MRI showed stabilization of some lesions and improvement in others. Hydroxychloroquine was added as a steroid-sparing agent due to the patient's history of osteoporosis.

Figure 6.

Spine magnetic resonance imaging without contrast STIR (short tau inversion recovery), sagittal view demonstrating axial sarcoid disease. Circle indicates pathological L4 compression fracture. Arrows indicate multiple sarcoid bony lesions.

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