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Case report of osteolytic lesions in a patient with multisystem granulomatous disease
  1. Henco Nel1,
  2. Brad Davis2,
  3. Brendan Adler3 and
  4. Eli Gabbay4
  1. 1Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
  2. 2SKG Radiology, St John of God Subiaco, Perth, Western Australia, Australia
  3. 3Envision Medical Imaging, Perth, Western Australia, Australia
  4. 4School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
  1. Correspondence to Dr Henco Nel; henco.nel{at}


We present a case of a 70-year-old Caucasian woman with multisystem granulomatous disease involving her lungs, bones and lymph nodes. The patient initially presented with cervical lymphadenopathy and subsequently developed progressive breathlessness. Imaging revealed extensive mediastinal, hilar and intra-abdominal lymphadenopathy as well as bilateral pulmonary parenchymal infiltrates. Lymph node and lung biopsy confirmed non-necrotising granulomatous inflammation while a BAL showed scanty growth of Cryptococcus neoformans and moderate growth of Staphylococcus aureus. The patient received intravenous ceftriaxone and had a good response to treatment. She also completed 3 months of oral fluconazole. Although a diagnosis of sarcoidosis was considered most likely, the patient was not initially started on systemic corticosteroids due to concern around possible infection and initial response to antimicrobials. However, her exercise tolerance gradually deteriorated. A craniofacial CT revealed multiple lytic lesions involving the skull and visualised cervical spine. Biopsy of a clivus lesion revealed non-necrotising granulomatous inflammation while fungal cultures and histopathological stains were negative. The patient was diagnosed with widespread sarcoidosis and she was initiated on prednisolone and methotrexate which led to marked clinical and radiological improvement.

  • interstitial lung disease
  • cryptococcus
  • respiratory system
  • radiology

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  • Contributors HCN wrote the manuscript and did the literature review. BD and BA assisted with the selection of radiological images and their appropriate captions as well as the appropriate radiological descriptions in the text. EG is the senior author who supervised the work and proofread the text.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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