case_images: PMC6925686_01
case_images: Contrast-enhanced CT of the abdomen pelvis demonstrates an enlarged and heterogeneous spleen (asterisk (a)) and multiple nonspecific sclerotic osseous lesions within the lumbar spine and sacrum (arrows (b)).
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case_images: PMC6925686_01_CRIRH2019-4156313.001.jpg
case_images: fig1
case_images: Contrast-enhanced computed tomography (CT) images of his abdomen and pelvis revealed an enlarged and heterogeneous spleen as well as numerous small nonspecific primarily sclerotic osseous lesions in his lower thoracic spine, lumbar spine, and pelvis without additional CT findings of concern (Figure 1).
case_images: PA and lateral chest radiographs obtained 5 years earlier (a, b) show mild convexity at the AP window (arrow) and subtle perihilar fullness (arrowheads) which in retrospect may have corresponded to lymphadenopathy rather than enlarged pulmonary arteries as initially interpreted. However, chest radiographs at current presentation (c, d) show no evidence of pulmonary or mediastinal disease.
case_images: CRIRH2019-4156313.002.jpg
case_images: PMC6925686_01_CRIRH2019-4156313.002.jpg
case_images: fig2
case_images: A chest radiograph performed in the emergent setting approximately five years earlier for an episode of chest pain was interpreted at that time as being notable only for an abnormal convexity in the region of the aortopulmonary window, likely due to a mildly enlarged main pulmonary artery (Figure 2). However, a new chest radiograph performed at the time of current presentation revealed neither residual mediastinal contour abnormalities nor perihilar fullness to suggest active pulmonary or mediastinal involvement of disease (Figure 2).
case_images: T1-weighted (a, c) and STIR (b, d) coronal MR images of the pelvis prior to treatment (top row) and following treatment (bottom row) show numerous small intramedullary foci of low signal on T1 and high signal on STIR (representative arrows), which essentially resolve following treatment.
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case_images: PMC6925686_01_CRIRH2019-4156313.003.jpg
case_images: fig3
case_images: MRI of the lumbar spine and right hip were obtained to evaluate the osseous lesions identified on CT and to further elucidate the source of pain localizing to the right hip, groin, and low back. MR images showed innumerable small enhancing intraosseous lesions throughout the pelvis (Figure 3), lower thoracic spine, and lumbar spine, findings favored to correspond to polyostotic skeletal involvement of sarcoidosis given the clinical scenario. Approximately 10 months following the initial MRI and 9 months following the initiation of MTX, a repeat contrast-enhanced MRI of the pelvis and lumbar spine demonstrated a marked reduction in quantity, size, and degree of enhancement associated with the previously described innumerable intraosseous lesions in the pelvis and spine, imaging features consistent with significant regression of skeletal sarcoidosis (Figure 3).
case_images: Contrast-enhanced T1 fat-saturated axial images at the level of the SI joints prior to (a) and following (b) treatment show characteristic low signal "ghosts" (white arrows (b)) at sites of prior-enhancing osseous lesions (black arrows (a)) indicating fibro-fatty tissue at these locations.
case_images: CRIRH2019-4156313.004.jpg
case_images: PMC6925686_01_CRIRH2019-4156313.004.jpg
case_images: fig4
case_images: The presence of aforementioned low signal "ghosts" could be observed at sites of previously evident disease foci (Figure 4).