Introduction Muscle involvement is a frequent histopathologic feature of sarcoidosis, but its symptomatic clinical presentation has been rarely reported. Muscle mass presenting as the only initial symptom of systemic disease has never been reported.
History A 55-year-old white female presented with complaints of a mass lesion in her left calf muscle. She had no other systemic symptoms at that time. She had no history of cough, hemoptysis, weight loss, or any bowel/bladder problems. A detailed review of the system was completely negative for the signs and symptoms of any systemic illness, including a rheumatologic disease process. Her physical examination was only positive for a 4 × 2 cm left calf mass. A detailed systemic evaluation, including blood chemistries and serology, was unremarkable. MRI of the mass lesion showed characteristic findings; subsequent excision biopsy of the mass was positive for noncaseating granulomas consistent with the diagnosis of sarcoidosis. Further workup showed hilar lymphadenopathy on chest radiography, which was confirmed by CT scan; no malignant process or any active interstitial lung disease was noted. ACE level was 83, ESR 22, CRP 0.3, and CPK 94. Again, she had no pulmonary symptoms. No further treatment was given to her at that time, but the lump recurred after 6 months. She still elected not to receive any therapy. During her 2 years of follow-up, she has remained asymptomatic, without an increase in the size of the lump.
Discussion Sarcoidosis is a multisystemic disorder of unknown etiology. Patients with sarcoidosis frequently present with bilateral hilar lymphadenopathy and pulmonary infiltration and often with ocular and skin lesions. Muscles are involved as part of the multisystem disease process, but muscle mass as the only initial presentation has never been reported. Sarcoid myopathy may demonstrate either myopathic or nodular type involvement. Nodular sarcoid myopathy has a characteristic MR appearance that allows accurate diagnosis. It appears as focal intramuscular masses, usually at the musculotendinous junction, which are often multiple and bilateral in distribution and have a lower extremity predominance. It is usually associated with distinctive laboratory abnormalities, including hyperglobulinemia, an elevated serum ACE, and hypercalcemia. Glucocorticoids remain the mainstay of therapy when treatment is required, although other immunosuppressive agents are being used increasingly. This patient has required no treatment and has remained stable for 2 years, highlighting wide variation in the course of this severe systemic illness.
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