Jamali A R, Ghulam Mehboob.
Sarcoidosis of spine.
J Coll Physicians Surg Pak Jan ;9(3):160-2.

This is case report of sarcoidosis of T8-9 spine, which presented with local pain and tenderness along with hypoasthesia in left ninth intercostal nerve. The investigations revealed reduced T8-9 disc space with sclerosis and bilateral hilar lymphadenopathy. Further investigations revealed multisystem involvement. Her angiotensin converting enzyme level was significantly high. Her mediastinal biopsy revealed noncaseating granuloma. The discussion mainly focus on various aspects of sarcoidosis.

CASE REPORT: A forty two years old lady presented with hypoasthesia in the distribution of right ninth intercostal nerve and ill defined pain in the region of T7 to T vertebrae which was worse at night for last two months. She was tender at T8 and T9 vertebrae. Her initial plain x-rays of dorsal spine showed reduced disc space at T8-9 with sclerosis and osteophyte formation. Her base line investigations revealed Hb 14 gm%, WBC count 7800, neutrophils 60%, lymphocytes 30%, sugar 131 mg%, urea 21% and 6-8 leucocytes/HPF in urine analysis. ESR was 72 mm/1st hour. These findings were suggestive of tuberculosis of spine, however her Montoux test was negative, and sputum showed no acid fast bacilli. X-ray chest did not reveal any active lung lesion but showed prominent hilar shadows. Technitium scan did not show abnormal up take. MRI revealed degeneration with narrowing of T8 and T9 disc space without bone or marrow destruction. It also revealed massive hilar lymphadenopathy. C.T Scan of chest also showed hilar lymphadenopathy but no lesion in lungs, bone or vessels. C.T guided biopsy of the spine was not possible because of lack of suitable window, she was advised mediastinoscopy and lymph node biopsy. While waiting for above procedure, she developed bilateral facial nerve palsy and was referred to a neurophysician who advised number of investigations. The following were significant. RA factor and anti (m) DNA were reactive. The serum levels of following were, Mg 2.2 (range 1.5-2), CPK 91 (range 10-80), alkaline phosphatase 1256 p/l (range 80-306), SGPT 177 (N.R 9.4-43.3); yGT 200 (range 11-50) and angiotensin converting enzyme 82.3 P/1 (range 852). Total proteins were 8.9 gm % (range 6.6-8.7) with albumin 4.8 (range 3.8-4.4) and globulins 4.1 gm% (range 1.8-3.6). The nerve conduction studies showed axonopathy of both facial nerves and mild changes in left peroneal nerve. The MRI of brain revealed ischaemic lesion in left anterior parietal lobe. Mediastinal lymph node biopsy showed effaced architecture and replacement by many compact granulomas composed of epitheloid cells and Langhans type giant cells. No caseation necrosis or malignancy seen. On the basis of above findings she was diagnosed as a case of sarcoidosis and was put on oral steroid therapy. Clinical improvement occurred as pain subsided and numbness improved. Right side facial palsy recovered, ESR decreased to 42 mm/1st hour and angiotensin converting enzyme level to level of 43 p/1.

PakMediNet -Pakistan's largest Database of Pakistani Medical Journals - http://www.pakmedinet.com