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Images of Memorable Cases: Case 139

Module by: Herbert L. Fred, MD, Hendrik A. van Dijk

http://rup.rice.edu/memcases-button.jpg

Case_139-pres1-1.jpg

This 36-year-old man presented with a two-year history of swelling and limited motion of both hands. On examination, the fingers were swollen, nontender, and boggy to palpation, with normal overlying skin. The interphalangeal joints moved little, if at all, but the wrists and metacarpophalangeal joints were normal. No other bone or joint disease was evident.

Case_139-pres1-2.jpg

Radiographically, cystic destructive lesions affected most of the phalanges of both hands; the interphalangeal joint spaces were narrowed as well.

139. Advanced phalangeal sarcoidosis

In addition to his abnormal hands, this patient had bilateral hilar enlargement on chest radiograph and biopsy-proven sarcoidal facial papules.

The incidence of osseous sarcoidosis ranges from 2% to 30% in most series. Although any bone can be affected, the hands and feet are the most frequent sites. Of the various radiographic features, lytic lesions predominate. Other findings include thickening of cortical bone with a fine, lacy, reticular alteration of the trabecular pattern, sclerosis of the distal phalanges, and gross destruction of the bone and joint.

Most bony involvement in sarcoidosis is asymptomatic and requires no treatment. If, however, pain, disability, or deformity becomes an issue, corticosteroid therapy can ease the discomfort and, in some cases, promote healing.

The differential diagnosis includes gout and granulomatous infections such as tuberculosis and fungal disease.

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