Presentation
Hand pain.
Patient Data
There is well-defined lytic destruction of the first proximal phalanx and 2nd metacarpal, with a preserved honeycomb trabecular pattern in these areas. These lesions extend throughout the entire length and diameter of the involved bones. The 2nd metacarpal is mildly expanded overall, with irregular areas of calcification along the ventral and radial aspect of the diaphysis likely representing callus formation from a healing pathological fracture.
The exostotic area along the ulnar aspect of the 5th metacarpal is likely from previous fracture, given the anterior angulation at this site. Multiple traction enthesophytes are noted along the medial and lateral aspects of the phalanges (e.g. 4th proximal).
Case Discussion
Path proven sarcoidosis.
Osseous involvement with sarcoidosis is rare (~1-13%), however when it occurs it is common in the hands, and classically presents with a honeycomb/latticework trabecular pattern, as is seen in this case. Acroosteolysis with or without sclerosis may also be seen.
Spina ventosa of tuberculosis and other granulomatous infections would be reasonable differential considerations in this case, however the findings seen here are quite characteristic for sarcoidosis. Other differential thoughts include the cyst-like foci seen in tuberous sclerosis, enchondromatosis, fibrous dysplasia, musculoskeletal hemangiomatosis and hyperparathyroidism.
Case images courtesy of Jamie Bedle, DC, DACBR.