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Illustration 1. The patient, a 54-year-old woman, presented for evaluation of refractory neck pain and headache. The patient's medical history was positive for stage I pulmonary sarcoidosis. Computed tomography (CT) scan of the head revealed a lytic lesion involving the frontal and parietal calvarium (A). Cervical spine CT scan showed multilevel heterogeneous osseous abnormalities, most notably involving the left anterolateral arch of C1 (B). Initial differential diagnosis was broad and included infection and malignancy, as well as osseous sarcoidosis given the patient's pulmonary disease. Results of laboratory work showed hypercalcemia with normal renal function and normal hemoglobin and hematocrit values. Results of serum and urine protein electrophoresis were negative, and findings of a skeletal survey were negative for other new lesions. Calvarial biopsy was performed and results were positive for noncaseating granulomas. Results of special staining for atypical mycobacterial and fungal organisms were negative. The patient was diagnosed as having osseous sarcoidosis affecting her skull and cervical spine, based on the characteristic noncaseating granulomas found on biopsy, negative results on tests for infection and malignancy, and her history of pulmonary sarcoidosis. Initial treatment consisted of 60 mg of prednisone daily followed by a slow taper. However, repeat imaging 3 months later showed progression of the cervical spine lesion with the potential for spinal cord compression. She was treated with high-dose intravenous corticosteroids and underwent cervical spinal fusion for stabilization of her vertebral column. This case demonstrates an unusual presentation of sarcoidosis affecting the skull and cervical spine. Bony involvement of sarcoidosis typically affects the hands or feet and is reported in ∼3–13% of patients. There are few reports in the literature of sarcoidosis affecting the central skeleton. Corticosteroids remain first-line therapy for extrapulmonary sarcoidosis with bony involvement. Osseous sarcoidosis should be considered during the differential diagnosis when evaluating new lytic lesions of the skull and axial skeleton in a patient with pulmonary sarcoidosis.

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