Osteosclerotic Lesions in Sarcoidosis Report of a Case
RALPH C. MARCOVE, M.D.,* RONALDROONEY,M.D.** LAWRENCE D. WEIS, M.D.**
The purpose of this report is to describe a case of sarcoidosis producing multiple osteoblastic lesions of the pelvis which were initially thought to be metastatic carcinoma. Sarcoidosis is a multisystem disease which affects bone in about 14% of cases and characteristically produces lytic lesions involving small bones of the hands and feet.315 Arthritic changes and pathologic fractures in sarcoidosis have been well documented.317 The less common vertebral lesions are primarily destructive and may show some marginal sclerosis1 but purely blastic lesions are rare.4**Recently we had the opportunity to observe an individual with pulmonary sarcoidosis, arrested since 1970, and multiple sclerotic lesions of the pelvis without other skeletal manifestations.
* Associate Attending, Memorial Hospital SloanKettering Institute, Associate Attending, Hospital for Special Surgery, Chief, Bone Tumor Service, Hospital for Joint Diseases, Clinical Associate Professor of Surgery, Cornell University Medicial College. * * Fellow in Orthopedic Oncology, Memorial Hospital, Sloan-Kettering Institute. Reprint requests: Ralph C. Marcove, M. D., 517 East 7 1 Street, New York, New York 10021. Received: June 27, 1977. 0
CASE REPORT This 36-year-old Negro man from Georgia was seen for further evaluation of osteoblastic pelvic lesions on X-ray. The patient had a 30month history of low back pain radiating to the posterior aspect of both thighs. He had been admitted to another hospital where a myelogram was normal but the incidental finding of a sclerotic lesion in the pelvis caused his referral. Past history revealed a supraclavicular node biopsy in 1968 which revealed moncaseating granuloma compatible with sarcoidosis. This was followed by a chronic, nonproductive cough for 6 months and development of chest X-ray findings also confirmatory for sarcoidosis. The patient was treated for 2 years with steroids and had been apparently in complete remission since 1970. Physical exam was generally unremarkable except for generalized low back pain upon straight leg raising beyond 60-70" bilaterally. X-rays of the pelvis revealed multiple well defined sclerotic densities in both iliac wings (Fig. 1 ) and chest films showed old, inactive pulmonary disease (Fig. 2). Bone scan showed positive areas of uptake in the pelvis. Laboratory tests showed calcium 9.7; phosphorous 3.1 ; alkaline phosphotase 7 1 ; total protein 8.2; albumin 4.3. Complete blood count: H b 11.8; Hct. 35.7; WBC 4.5; Differential: polys 61; monos 11; lymphs 28. Submitted slides from the 1968 biopsy showed noncaseating granuloma in supraclavicular
Number 129 November-December, I977
FIG. 1. A P Pelvis X-ray showing lesion. lymph nodes with special stains for acid-fast bacilli and fungi negative. An open surgical biopsy was performed on the iliac wing and pathologic examination revealed multiple noncaseating granulomas withi n the bone marrow. The osseous trabeculae in the area were thickened and sclerotic and special stains for acid fast organisms and fungi were negative (Figs. 3A and B ) . The patient's postoperative course was uneventful.
DISCUSSION Osseous manifestations of sarcoidosis are relatively infrequent but well known, occurring in 5.3% to 26% of cases.*.S Characteristically they involve the phalanges, metacarpals and metatarsals of the hands and
FIGS.3A and B. Photomicrograph of lesion, low and high power.
FIG. 7. AP Chest film demonstrating old ti i sease.
feet, producing small, well defined, punchedout lytic lesions.'. 3 Reticular lysis and cortical thinning are the earliest roentgenographic signs of this involvement and subsequently the punched-out lesions which develop are small and generally lack marginal sclerosis.7 Rodman, et al., first described the less common vertebral lesions of sarcoidosis and with other reports have pointed out that these primarily destructive lesions do show mar-
Clinical Orthopaedics and Related Research
Marcove, Rooney and Weis
SUMMARY In a 36-year-old black American male, sarcoidosis produced multiple osteoblastic lesions instead of the lytic lesion characteristic of the disease. REFERENCES 1. Baldwin, D. M.,Roberts, J. G. and Croft, H. E.: Vertebral sarcoidosis, J. Bone Joint Surg. 56:629, 1974.
FIG.4. AP Hand X-ray, negative for lesions.
ginal sclerosis.2.3,6 There have been two previous case reports involving osteosclerotic changes in multiple bones4*8 similar to those described here, but this case lacks any other skeletal manifestations, especially lesions of the hands or feet (Fig. 5 ) , which to our knowledge has not been previously reported. These bone lesions apparently developed 6 years after arrest of the patient’s pulmonary disease and have been documented by laboratory data and biopsy. The physician should therefore be aware of this unusual presentation of sarcoidosis when considering the differential diagnosis of multiple osteoblastic lesions of bone.
2. Berk, R. N. and Brower, T. C.: Vertebral sarcoidosis, Radiology 82:660, 1964. 3. Bjarnason, D. F., Forrester, D. M. and Swezey, R. L.: Destructive arthritis of the large joints, J. Bone Joint Surg. 55:618, 1973. 4. Bonakdarpour, A., Levy, W. and Aegerter, E. E.: Osteosclerotic changes in sarcoidosis, Am. J. Roentgenol. Radium. Ther. Nucl. Med. 113:646, 1971. 5. Mayock, R. L., Bertrand, P., Morrison, C. E.
and Scott, J. H.: Manifestation of sarcoidosis, Am. J. Med. 35:67, 1963. 6. Rodman, T., Funderbunk, E. E., Jr. and Myerson, R. M.: Sarcoidosis with vertebral involvement, Ann. Intern. Med. 50:213, 1959. 7. Watson, R. C. and Cahen, 1.: Pathological fracture in long bone sarcoidosis, J. Bone Joint Surg. 55:613, 1973. 8. Young, D. A. and Laman, M. L.: Radiodense skeletal lesions in Boeck’s sarcoid, Am. J. Roentgenol. Radium. Ther. Nucl. Med. 114: 553, 1972. 9. Zener, J. C., Alpert, M. and Klainer, L. M.:
Vertebral sarcoidosis, Arch. Intern. Med. 11 1 :696, 1963.