HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Campbell, S. E. Articles by Fillman, E. Search for Related Content PubMed PubMed Citation Articles by Campbell, S. E. Articles by Fillman, E. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?

Vertebral and Spinal Cord Sarcoidosis

¹ Department of Radiology and Nuclear Medicine, Wilford Hall Medical Center, Lackland Air Force Base, TX 78236-5300.
² Department of Radiology, Brooke Army Medical Center, 3851 Roger Brooke Dr., San Antonio, TX 78234.
³ Department of Radiology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1088.

Received October 28, 2004; accepted after revision November 29, 2004.

Address correspondence to L. T. Bui-Mansfield (liem_mansfield{at}gmail.com).

The opinions and assertions contained herein are those of the authors and should not be construed as official or as representing the opinions of the Department of the Army or Department of Defense.

A 64-year-old woman with a history of sarcoidosis presented with back and abdominal pain and was unresponsive to nonsteroidal anti-inflammatory medications. In addition, the patient complained of weakness in her right arm. Physical examination of the abdomen was unremarkable, and examination of the spine revealed normal flexion and extension and no focal tenderness. Neurologic examination revealed slightly decreased strength in the right arm and hand.

A posteroanterior chest radiograph showed a bilateral diffuse reticulonodular pulmonary parenchymal pattern, right paratracheal stripe thickening, and bilateral hilar lymphadenopathy (Fig. 1A). CT of the chest confirmed bilateral hilar, right paratracheal, and subcarinal lymphadenopathy and interstitial pulmonary disease. CT also revealed widespread retroperitoneal lymphadenopathy and multiple lytic lesions within the vertebral bodies and posterior elements of the thoracolumbar spine. Subsequent MRI of the spine revealed decreased T1 signal intensity and increased T2 signal intensity scattered throughout the spine (Fig. 1B). After IV sodium gadopentate was administered to the patient, multiple brightly enhancing lesions within the vertebral bodies, pedicles, laminae, and spinous processes were identified. Diffuse leptomeningeal and nerve root enhancement and an enhancing parenchymal spinal cord mass were also present (Fig. 1C).

View larger version (122K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —64-year-old woman with vertebral and spinal cord sarcoidosis. Posteroanterior chest radiograph shows bilateral hilar prominence (arrowheads) and right paratracheal stripe thickening (arrow) secondary to lymphadenopathy, which was confirmed by CT (not shown). Note is also made of diffuse bilateral reticulonodular interstitial lung disease.

View larger version (79K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —64-year-old woman with vertebral and spinal cord sarcoidosis. Sagittal T1-weighted MR image of cervical and thoracic spine shows decreased signal scattered throughout vertebral bodies. Subcarinal lymphadenopathy (arrow) is noted.

View larger version (88K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —64-year-old woman with vertebral and spinal cord sarcoidosis. Sagittal T1-weighted MR image obtained after administration of sodium gadopentate reveals multiple brightly enhancing regions within vertebral bodies and spinous processes. In addition, enhancing mass can be seen within spinal cord at C6-7 disk level. Note dural enhancement in thoracic spine (arrow).

Biopsy of a vertebral lesion revealed noncaseating granuloma consistent with sarcoidosis without evidence of malignancy (Fig. 1D). Gram stains and cultures for fungi, aerobic and anaerobic organisms, and acid-fast bacilli were all negative.

View larger version (149K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D. —64-year-old woman with vertebral and spinal cord sarcoidosis. Photomicrograph of biopsy specimen shows absence of central necrosis, which is consistent with noncaseating granuloma (arrow) of sarcoidosis without malignant cells. (H and E, x400)

The differential diagnosis for diffuse marrow infiltration, enhancing intraaxial spinal cord mass, diffuse meningeal and nerve root enhancement, and mediastinal and retroperitoneal lymphadenopathy includes metastatic disease, lymphoma, leukemia, hematogenous osteomyelitis (tuberculous, fungal), and sarcoidosis [1].

Sarcoidosis is a systemic granulomatous disease of unknown etiology that has been shown to affect nearly every organ system. Osseous involvement occurs in 1–13% of cases, typically in the small tubular bones of the hands and feet [2, 3]. Sarcoidosis may affect either the vertebral column or the spinal cord. Typical vertebral column manifestations are lytic lesions with sclerotic borders that enhance on MRI and enhancement of the intervertebral disk [1, 3–5]. Typical spinal cord manifestations are leptomeningeal enhancement, enhancing spinal cord mass, nerve root "clumping," and enhancing nerve root [4]. The most common spinal cord manifestation is leptomeningeal disease [4]. Given the variable manifestations of sarcoidosis within the spine, this disease should be considered in the differential diagnosis along with multiple sclerosis [4]; tuberculous meningitis [4]; and widespread vertebral involvement of metastatic disease, infection, or lymphoma [1].

Sarcoidosis is typically treated with corticosteroid therapy, after which clinical symptoms and even MRI findings may completely or partially resolve in 29% of the patients [6]. Prednisone (15–40 mg/day) adjusted to the severity of pain and gradually tapered over 6–12 months is a typical regimen [3]. Alternative treatments may include methotrexate, azathioprine, hydroxychloroquine, and cyclophosphamide [6]. In some patients, neurologic compromise or complications such as vertebral body compression fracture may require surgical intervention [3].

References

1. Stump D, Spock A, Grossman H. Vertebral sarcoidosis in adolescents. Radiology1976; 121:153 –155[Abstract]
2. Rockoff SD, Rohatgi PK. Unusual manifestations of thoracic sarcoidosis. AJR1985; 144:513 –528[Abstract/Free Full Text]
3. Rua-Figueroa I, Gantes MA, Erausquin C, Mhaidli H, Montesdeoca A. Vertebral sarcoidosis: clinical and imaging findings. Semin Arthritis Rheum 2002;31:346 –352[Medline]
4. Lexa FJ, Grossman RI. MR of sarcoidosis of the head and spine: spectrum of manifestations and radiographic response to steroid therapy. Am J Neuroradiol1994; 15:973 –982[Abstract]
5. Fisher AJ, Gilula LA, Kyriakos M, Holzaepfel CD. MR imaging changes of lumbar vertebral sarcoidosis. AJR1999; 173:354 –356[Free Full Text]
6. Zajicek JP, Scolding NJ, Foster O, et al. Central nervous system sarcoidosis: diagnosis and management. QJM1999; 92:103 –117[Abstract/Free Full Text]

CiteULike

Complore

Connotea

Del.icio.us

Digg

Reddit

Technorati

This Article Figures Only Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Campbell, S. E. Articles by Fillman, E. Search for Related Content PubMed PubMed Citation Articles by Campbell, S. E. Articles by Fillman, E. Social Bookmarking                      What's this? Hotlight (NEW!) What's Hotlight?