Sarcoidosis presenting as granulomatous myositis in a 16-year-old adolescent.
BACKGROUND
Sarcoidosis is a multi-system disease characterized by the presence of non-caseating epithelioid granulomas in affected tissues, including skeletal muscle. These organized collections of immune cells have important pathophysiologic action including cytokine production leading to inflammation as well as enzymatic conversion of cholecalciferol to calcitriol via 1-α hydroxylase. There are limited reports of isolated granulomatous myositis causing hypercalcemia in pediatric patients. Our patient uniquely presented with symptoms from hypercalcemia and renal insufficiency caused by an overwhelming burden of granulomatous myositis in her lower extremities, but was otherwise asymptomatic.


METHODS
A 16 year old Caucasian female presented with protracted symptoms of fatigue, nausea and prominent weight loss with laboratory evidence of hypercalcemia and renal insufficiency. She lacked clinical and physical findings of arthritis, weakness, rash, uveitis, fever, lymphadenopathy or respiratory symptoms. After extensive negative investigations, re-examination yielded subtle soft tissue changes in her lower extremities, with striking MRI findings of extensive myositis without correlative weakness or serum enzyme elevation. Biopsy showed the presence of non-caseating epithelioid granulomas and calcium oxalate crystals. The patient responded well to prednisone and methotrexate but relapsed with weaning of steroids. She reachieved remission with addition of adalimumab.


CONCLUSIONS
Sarcoidosis should be considered in patients presenting with symptomatic hypercalcemia with no apparent causes and negative routine workup. The absences of decreased muscle strength or elevated muscle enzymes do not preclude the diagnosis of granulomatous myositis.
Department of Pediatrics, Division of Rheumatology, Washington University School of Medicine, One Children's Place, Campus Box 8116, St. Louis, MO, USA.
Amir B
AB
Orandi
Department of Radiology, Division of Pediatric Radiology, Washington University School of Medicine, St. Louis, MO, USA.
Eric
E
Eutsler
Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA.
Cole
C
Ferguson
Department of Pediatrics, Division of Rheumatology, Washington University School of Medicine, One Children's Place, Campus Box 8116, St. Louis, MO, USA.
Andrew J
AJ
White
Department of Pediatrics, Division of Rheumatology, Washington University School of Medicine, One Children's Place, Campus Box 8116, St. Louis, MO, USA. kitcharo_m@kids.wustl.edu.
Maleewan
M
Kitcharoensakkul
D000068879:Adalimumab / Q000008:administration & dosage*; D000293:Adolescent; D018501:Antirheumatic Agents / Q000008:administration & dosage; D003937:Diagnosis, Differential; D005260:Female; D006099:Granuloma / Q000209:etiology / Q000473:pathology; D006801:Humans; D006934:Hypercalcemia / Q000175:diagnosis / Q000209:etiology; D008727:Methotrexate / Q000008:administration & dosage*; D018908:Muscle Weakness / Q000175:diagnosis / Q000209:etiology; D009220:Myositis / Q000209:etiology / Q000473:pathology / Q000503:physiopathology; D011241:Prednisone / Q000008:administration & dosage*; D051437:Renal Insufficiency / Q000097:blood / Q000175:diagnosis / Q000209:etiology; D012507:Sarcoidosis / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy / Q000503:physiopathology; D016896:Treatment Outcome
D018501:Antirheumatic Agents; D000068879:Adalimumab; D011241:Prednisone; D008727:Methotrexate
Adalimumab; Granuloma; Hypercalcemia; Myositis; Sarcoidosis