Pan-positive PET-CT - Metastasis or Multisystem Sarcoidosis?

Document Type

Conference Proceeding

Publication Date

5-21-2024

Publication Title

Am J Respir Crit Care Med

Abstract

Introduction Sarcoidosis is a multisystem granulomatous disorder of unknown etiology commonly affecting lungs, lymph nodes, skin and eyes. Less commonly, involvement of bones and spleen is seen. Description A 36-year-old woman with a history of mild childhood exercise-induced asthma developed an upper respiratory infection after exposure to sick contacts, after which she developed shortness of breath with no improvement with albuterol, budesonide-formoterol and a short steroid course. Her symptoms progressed to dyspnea with normal activity, wheezing and dry cough. Despite an unremarkable chest x-ray, CT and PET scans revealed nodular and ground-glass pulmonary parenchymal lesions, bony lesions, splenic involvement, and diffuse adenopathy in the neck, mediastinum and abdomen. Lesions were PET-avid and thought consistent with metastatic neoplasm. The patient had hypercalcemia. Pulmonary function testing (PFT) revealed airway obstruction with moderate to severe reduction in FEV1 with moderate diffusion impairment. The patient was diagnosed with sarcoidosis after multiple sites were biopsied to include transbronchial lung, cervical lymph node and bone with non-caseating granulomas. She was prescribed daily prednisone, methotrexate, and mometasone-formoterol, which gradually led to improvement in shortness of breath and resolution of serum hypercalcemia. A CT scan one year later showed improvement in thoracic lymphadenopathy and pulmonary nodules and marked improvement in bony lesions. The patient developed tachycardia but did not have evidence of active cardiac involvement. The patient failed initial sarcoidosis therapy when she developed calcium oxalate kidney stones and hypercalciuria despite having a normal serum calcium level. Infliximab was added to her treatment regimen with resolution of hypercalciuria. The patient subsequently had gradual onset of sarcoid arthropathy, worsened with cold exposure and is being considered for hydroxychloroquine. Discussion Bone involvement is rarely seen in sarcoidosis and is usually asymptomatic and discovered incidentally as in our case. Osseous lesions often mimic metastases, difficult to differentiate on imaging. Splenic involvement is rarely seen in sarcoidosis, is usually nodular rather than diffuse as is in this case, and is a risk factor for chronic sarcoidosis with extrapulmonary involvement. Hypercalciuria without hypercalcemia in sarcoidosis has previously been reported and is an indication for aggressive treatment. Prompt biopsy ruled out malignancy in this patient and revealed sarcoidosis. This patient displayed a constellation of unusual findings due to sarcoidosis, including multiple lesions mimicking metastatic neoplasm, diffuse splenic involvement, and hypercalciuria and nephrolithiasis without hypercalcemia. Biopsy is vital for accurate diagnosis and timely management of sarcoidosis.

Volume

209

Issue

9

First Page

A5899

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