An unusual case of sarcoidosis

Case report A 42-year-old male patient with sarcoidosis, hepatitis C, COPD and previous substance abuse attended routine follow-up in May 2011. Sarcoidosis had been diagnosed in 2002 based on a clinical picture of weakness, relapsing fever, generalized lymphadenopathy, dyspnoea and myalgia together with a lymph node biopsy showing typical granulomas. Tuberculosis had been excluded. In March 2010, the disease had been stable, with stationary findings of hilar lymphadenopathy and reduced diffusion capacity. In May 2011 the patient felt well but reported mild neck and shoulder pain for the past two months and a new skin lesion on the left lateral chest wall. Chest x-ray showed numerous additional lesions up to 1.5 cm in diameter (Figure 1), and a CT chest was performed (Figure 2). This confirmed multiple pulmonary nodules which were consistent with, but not typical for, sarcoidosis. Two weeks later he developed intense neck pain and mild tetraparesis. MRI showed a space-occupying lesion with destruction of the C2 vertebra and spinal cord compression (Figure 3). We carried out a biopsy, which revealed a diffuse large B-cell non-Hodgkin’s lymphoma stage IV AE with IPI risk score 3 (high-intermediate). Following surgical decom-pression and six cycles of R-CHOP chemotherapy, the weakness resolved and the patient remains lymphoma recurrence free one year later. His sarcoidosis has never required treatment.