Rare Case: Sarcoidosis Presenting as Low Back Pain

Berianu F, Ginsburg WW, Amoateng-Adjepong Y. Herniated Lumbar Disk as the Initial Presentation of Sarcoidosis. Am J Med (2014) March 22. DOI: http://dx.doi.org/10.1016/j.amjmed.2014.01.013

Bony involvement is a rare, late involvement of sarcoidosis. In this unique case, the initial presentation of sarcoidosis was involvement of the vertebrae, which responded well to hydroxychloroquine.

A 56-year-old woman presented with progressive lower back pain and paresthesias of the left leg.

Magnetic resonance imaging (MRI) showed a herniated L4-L5 disk and abnormal bone marrow signal in the L1 and L4 vertebral bodies. Computed tomography (CT) showed enlarged hilar and mediastinal lymph nodes, and multiple reticulonodular opacities in both lung fields.

She had an L4-L5 laminectomy with posterolateral fusion and intraoperative biopsy of the L4 body. The biopsy found noncaseating granuloma, consistent with sarcoidosis.

She was treated with hydroxychloroquine and oral prednisone for eight weeks, and then only hydroxychloroquine.

Three months later, MRI showed a reduction in the L1 signal and stable L4 signal. CT two years later showed a decrease in size of the mediastinal lymph nodes and complete resolution of the opacities in both lungs. She is now asymptomatic.

The diagnosis of vertebral sarcoidosis requires evidence of other systematic involvement, and histological evidence of noncaseating granuloma. A bone biopsy is necessary to exclude malignancy and other diseases.

Osseous sarcoidosis responds poorly to corticosteroids. Steroid-sparing agents have variable responses. This case confirms the effectiveness of hydroxychloroquine.