Learning Radiology xray montage

Skeletal Sarcoid
Osseous Manifestations of Sarcoidosis

General Considerations

  • Radiographic evidence of osseous involvement occurs in about 5% of patients with sarcoidosis
    • Arthralgia in patients with sarcoid may occur in up to 1/3 of patients
  • Patients are usually between 20-40, more frequently women
  • Typically affects multiple joints
  • Most often affects hands, feet and ankles (the latter in acute form)
    • Lesions in long bones, skull or spine are rare
  • Often occurs in association with pre-existing pulmonary and/or skin lesions such as lupus pernio
    • Purplish, indurated macules or papules on the face considered classic for sarcoid
  • May occasionally be presenting manifestation of sarcoid

Clinical Findings

  • Frequently asymptomatic
  • Joint manifestations include
    • Stiffness
    • Pain
    • Soft tissue swelling
  • Soft tissue nodules (granulomas)
  • Erythema nodosum, especially in acute form

Imaging Findings

  • Usually bilateral and symmetric
  • Middle and distal phalanges of hands and feet most frequent sites of involvement
    • Tends to spare the wrists
  • Distal portions of small bones of hands and feet tend to be affected first
  • Patterns of osseous sarcoidosis
    • Small, cortical, punched-out lytic lesions, usually well-corticated,  in the phalangeal heads are most common manifestation
      • Some been described as heart-shaped as in this case
    • Reticular (permeative) pattern produces a lace-like (driftwood) pattern of destruction
    • Acro-osteosclerosis of the terminal phalanges (bone stones)
      • Not specific but can occur in up to 50% of patients with sarcoid of hands
      • May represent healing phase
    • Acro-osteolysis resembling scleroderma
    • Bone destruction with pathologic fractures
      • Usually with soft tissue swelling but without periosteal reaction
    • Subperiosteal resorption resembling hyperparathyroidism
    • Soft tissue nodules
  • Although plain films are usually adequate to make the diagnosis, MR may show additional or unsuspected lesions in bone and soft tissues


Chronic Osseous Manifestations of Sarcoid

Punched-out lytic lesions

Lace-like destruction

Bone stones (acro-osteosclerosis)

Bone destruction with/without pathologic fracture


Subperiosteal resorption resembling hyperparathyroidism


Differential Diagnosis


  • Corticosteroids may decrease pain and swelling
  • Bone changes are irreversible in chronic form


  • Chronic osseous involvement is usually associated with diseases of other organs and has a poor prognosis

sarcoid of feet

Sarcoid of feet.
Frontal radiographs of both feet show multiple punched-out lytic lesions (red arrows) (one heart-shaped-white arrow), mostly in the proximal phalanges of both feet. There is also bone destruction and pathologic fractures of both third toes and the distal right 5th toe (black arrows).
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Radiographic, angiographic and radionuclide manifestations of osseous sarcoidosis.

Yaghmai, I. RadioGraphics Volume 3, Number 3 September 1983 pp. 375

Sarcoidosis: A Primary Care Review. Belfer, M; Stevens, R.  American Family Physician. December 1998

Sarcoid of bones  www.Gentili.net