When in Doubt, It's Always Sarcoid! A Peculiar Presentation of Sarcoidosis

Document Type

Conference Proceeding

Publication Date

5-17-2022

Publication Title

Am J Respir Crit Care Med

Abstract

Introduction: Sarcoidosis is an idiopathic systemic inflammatory disease that usually presents with pulmonary manifestations. Diagnosis is confirmed by histopathological evidence of noncaseating granulomas after excluding other differentials. Case: We present a 61-year-old female patient with no significant medical history who presented with severe subacute back pain radiating to her chest. This pain has progressively worsened over a period of 8 months. She denied any other symptoms. A lumbar spine CT showed no spinal pathology, but the thoracic cuts showed innumerable centrilobular nodules throughout the lungs, so a CT chest was ordered which redemonstrated the nodules and showed bilateral multiple apical thin-walled cysts. Initially, our concern was ruling out miliary tuberculosis. After several failed attempts at expectoration, she underwent a bronchoscopy and lymph node biopsy which showed noncaseating granulomas with negative AFB stains. Her pain persisted prompting a bone scan to evaluate for potential bone involvement with sarcoid which was negative. Due to the neuropathic nature of her pain with negative workup otherwise, she was diagnosed with neurosarcoidosis with small fiber involvement and started on steroids with plans to work it up further as an outpatient with a lumbar puncture, EMG and MRI. On follow up, she reported remarkable improvement in her pain alongside a return to her baseline functional status. Discussion: Sarcoidosis typically presents with pulmonary symptoms. Our patient had unusual clinical and radiological manifestations. She presented with intolerable back pain and had miliary pulmonary nodules on CT. After her biopsy showed noncaseating granulomas, we diagnosed her with sarcoidosis and more specifically Neurosarcoidosis. Neurosarcoidosis is defined as the presence of evidence of sarcoidosis along with pertinent neurological symptoms. It is uncommon and is present in around 5% of all sarcoidosis cases. Spinal Neurosarcoidosis presents in about 0.43% of patients with a range of symptoms, including radiculopathy. Typically, sarcoidosis is indicated by bilateral hilar lymphadenopathy, but our patient had miliary pulmonary nodules which usually suggests infections such as tuberculosis or histoplasmosis. Miliary pulmonary sarcoidosis is rare with a prevalence of less than 1%. No randomized controlled trial researched the treatment of Neurosarcoidosis, but the consensus is to treat patients with glucocorticoids with bridge to DMARDs. Conclusion: Often, complaints of chronic pain are not addressed appropriately. Our patient has suffered from debilitating pain for 8 months which was largely overlooked. And although this presentation is rare, this case highlights the need to fully investigate a patient's symptom thoroughly.

Volume

205

Issue

1

First Page

A4074

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