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Musculoskeletal Sarcoidosis: Spectrum of Appearances at MR Imaging¹

¹ From the Department of Radiology, New York University School of Medicine, Tisch Hospital, 560 First Ave, New York, NY 10016 (S.M.); and the Department of Medicine, Pulmonary and Critical Care Division, Mount Sinai Medical School, New York, NY (A.E.T.). Presented as an education exhibit at the 2000 RSNA scientific assembly. Received November 21, 2002; revision requested January 2, 2003; revision received February 12; accepted February 21. Address correspondence to S.M. (e-mail: sandra.moore@med.nyu.edu).

View larger version (136K): [in a new window]   Figure 1. Small bone sarcoidosis. Close-up view from a posteroanterior radiograph of the finger shows sarcoidosis with the classic lacy lytic pattern involving the middle phalanx. The articular surface is spared.

View larger version (81K): [in a new window]   Figure 2a. Small bone sarcoidosis in a 53-year-old woman with a 12-year history of painful swelling of the digits. (a) Axial T2-weighted MR image (repetition time msec/echo time msec = 4,000/85) demonstrates swelling of the fifth finger with destruction of the cortex of the proximal phalanx. Periosseous extension of presumed sarcoidosis nodules with intermediate signal intensity is also seen (arrow). (b) Axial fat-saturated proton-density-weighted MR image (1,200/20) of the digits reveals a conglomerate nodular mass with bright signal intensity infiltrating the fifth proximal phalanx and destroying the cortex. (c) Coronal T1-weighted MR image (500/20) demonstrates a low-signal-intensity intramedullary mass of the fifth digit with fine perpendicular lines extending from the ghost of the cortex. Although this finding resembles periosteal reaction, it may represent periosseous extension of granulomas separated by fibroblasts and collagen. (d) Coronal fat-saturated proton-density-weighted MR image (2,000/22) also demonstrates fine perpendicular lines extending from the intramedullary lesion.

View larger version (80K): [in a new window]   Figure 2b. Small bone sarcoidosis in a 53-year-old woman with a 12-year history of painful swelling of the digits. (a) Axial T2-weighted MR image (repetition time msec/echo time msec = 4,000/85) demonstrates swelling of the fifth finger with destruction of the cortex of the proximal phalanx. Periosseous extension of presumed sarcoidosis nodules with intermediate signal intensity is also seen (arrow). (b) Axial fat-saturated proton-density-weighted MR image (1,200/20) of the digits reveals a conglomerate nodular mass with bright signal intensity infiltrating the fifth proximal phalanx and destroying the cortex. (c) Coronal T1-weighted MR image (500/20) demonstrates a low-signal-intensity intramedullary mass of the fifth digit with fine perpendicular lines extending from the ghost of the cortex. Although this finding resembles periosteal reaction, it may represent periosseous extension of granulomas separated by fibroblasts and collagen. (d) Coronal fat-saturated proton-density-weighted MR image (2,000/22) also demonstrates fine perpendicular lines extending from the intramedullary lesion.

View larger version (167K): [in a new window]   Figure 2c. Small bone sarcoidosis in a 53-year-old woman with a 12-year history of painful swelling of the digits. (a) Axial T2-weighted MR image (repetition time msec/echo time msec = 4,000/85) demonstrates swelling of the fifth finger with destruction of the cortex of the proximal phalanx. Periosseous extension of presumed sarcoidosis nodules with intermediate signal intensity is also seen (arrow). (b) Axial fat-saturated proton-density-weighted MR image (1,200/20) of the digits reveals a conglomerate nodular mass with bright signal intensity infiltrating the fifth proximal phalanx and destroying the cortex. (c) Coronal T1-weighted MR image (500/20) demonstrates a low-signal-intensity intramedullary mass of the fifth digit with fine perpendicular lines extending from the ghost of the cortex. Although this finding resembles periosteal reaction, it may represent periosseous extension of granulomas separated by fibroblasts and collagen. (d) Coronal fat-saturated proton-density-weighted MR image (2,000/22) also demonstrates fine perpendicular lines extending from the intramedullary lesion.

View larger version (158K): [in a new window]   Figure 2d. Small bone sarcoidosis in a 53-year-old woman with a 12-year history of painful swelling of the digits. (a) Axial T2-weighted MR image (repetition time msec/echo time msec = 4,000/85) demonstrates swelling of the fifth finger with destruction of the cortex of the proximal phalanx. Periosseous extension of presumed sarcoidosis nodules with intermediate signal intensity is also seen (arrow). (b) Axial fat-saturated proton-density-weighted MR image (1,200/20) of the digits reveals a conglomerate nodular mass with bright signal intensity infiltrating the fifth proximal phalanx and destroying the cortex. (c) Coronal T1-weighted MR image (500/20) demonstrates a low-signal-intensity intramedullary mass of the fifth digit with fine perpendicular lines extending from the ghost of the cortex. Although this finding resembles periosteal reaction, it may represent periosseous extension of granulomas separated by fibroblasts and collagen. (d) Coronal fat-saturated proton-density-weighted MR image (2,000/22) also demonstrates fine perpendicular lines extending from the intramedullary lesion.

View larger version (97K): [in a new window]   Figure 3a. Dactylitis in a 39-year-old man with sarcoidosis and hyperuricemia. (a) Posteroanterior radiograph of the hand shows eccentric swelling about the fifth digit. A faint erosion or cyst is seen at the medial margin of the proximal middle phalanx, along with cortical erosion in the distal phalanx. Gout was the favored radiologic diagnosis, but needle aspiration biopsy was not diagnostic. (b) Axial proton-density-weighted MR image (2,600/15) demonstrates low-signal-intensity material in the soft tissues about the second and fifth digits and extending into the medullary cavity of the fifth middle phalanx. (c-e) On axial fat-saturated T2-weighted (3,000/90) (c), coronal T1-weighted (450/10) (d), and coronal fat-saturated intermediate-density-weighted (1,600/16) (e) MR images, the paraosseous material remains low in signal intensity (arrows in d and e). A cystlike lesion whose contents demonstrate increased signal intensity is noted at the base of the fifth middle phalanx (arrowhead in e).

View larger version (72K): [in a new window]   Figure 3b. Dactylitis in a 39-year-old man with sarcoidosis and hyperuricemia. (a) Posteroanterior radiograph of the hand shows eccentric swelling about the fifth digit. A faint erosion or cyst is seen at the medial margin of the proximal middle phalanx, along with cortical erosion in the distal phalanx. Gout was the favored radiologic diagnosis, but needle aspiration biopsy was not diagnostic. (b) Axial proton-density-weighted MR image (2,600/15) demonstrates low-signal-intensity material in the soft tissues about the second and fifth digits and extending into the medullary cavity of the fifth middle phalanx. (c-e) On axial fat-saturated T2-weighted (3,000/90) (c), coronal T1-weighted (450/10) (d), and coronal fat-saturated intermediate-density-weighted (1,600/16) (e) MR images, the paraosseous material remains low in signal intensity (arrows in d and e). A cystlike lesion whose contents demonstrate increased signal intensity is noted at the base of the fifth middle phalanx (arrowhead in e).

View larger version (73K): [in a new window]   Figure 3c. Dactylitis in a 39-year-old man with sarcoidosis and hyperuricemia. (a) Posteroanterior radiograph of the hand shows eccentric swelling about the fifth digit. A faint erosion or cyst is seen at the medial margin of the proximal middle phalanx, along with cortical erosion in the distal phalanx. Gout was the favored radiologic diagnosis, but needle aspiration biopsy was not diagnostic. (b) Axial proton-density-weighted MR image (2,600/15) demonstrates low-signal-intensity material in the soft tissues about the second and fifth digits and extending into the medullary cavity of the fifth middle phalanx. (c-e) On axial fat-saturated T2-weighted (3,000/90) (c), coronal T1-weighted (450/10) (d), and coronal fat-saturated intermediate-density-weighted (1,600/16) (e) MR images, the paraosseous material remains low in signal intensity (arrows in d and e). A cystlike lesion whose contents demonstrate increased signal intensity is noted at the base of the fifth middle phalanx (arrowhead in e).

View larger version (153K): [in a new window]   Figure 3d. Dactylitis in a 39-year-old man with sarcoidosis and hyperuricemia. (a) Posteroanterior radiograph of the hand shows eccentric swelling about the fifth digit. A faint erosion or cyst is seen at the medial margin of the proximal middle phalanx, along with cortical erosion in the distal phalanx. Gout was the favored radiologic diagnosis, but needle aspiration biopsy was not diagnostic. (b) Axial proton-density-weighted MR image (2,600/15) demonstrates low-signal-intensity material in the soft tissues about the second and fifth digits and extending into the medullary cavity of the fifth middle phalanx. (c-e) On axial fat-saturated T2-weighted (3,000/90) (c), coronal T1-weighted (450/10) (d), and coronal fat-saturated intermediate-density-weighted (1,600/16) (e) MR images, the paraosseous material remains low in signal intensity (arrows in d and e). A cystlike lesion whose contents demonstrate increased signal intensity is noted at the base of the fifth middle phalanx (arrowhead in e).

View larger version (151K): [in a new window]   Figure 3e. Dactylitis in a 39-year-old man with sarcoidosis and hyperuricemia. (a) Posteroanterior radiograph of the hand shows eccentric swelling about the fifth digit. A faint erosion or cyst is seen at the medial margin of the proximal middle phalanx, along with cortical erosion in the distal phalanx. Gout was the favored radiologic diagnosis, but needle aspiration biopsy was not diagnostic. (b) Axial proton-density-weighted MR image (2,600/15) demonstrates low-signal-intensity material in the soft tissues about the second and fifth digits and extending into the medullary cavity of the fifth middle phalanx. (c-e) On axial fat-saturated T2-weighted (3,000/90) (c), coronal T1-weighted (450/10) (d), and coronal fat-saturated intermediate-density-weighted (1,600/16) (e) MR images, the paraosseous material remains low in signal intensity (arrows in d and e). A cystlike lesion whose contents demonstrate increased signal intensity is noted at the base of the fifth middle phalanx (arrowhead in e).

View larger version (124K): [in a new window]   Figure 4a. Large bone sarcoidosis in a 48-year-old man with left hip pain. (a) Anteroposterior radiograph shows the normal pelvis. (b, c) Coronal T1-weighted (450/8) (b) and fat-saturated intermediate-density-weighted (2,000/15) (c) MR images demonstrate numerous discrete round lesions within the lumbar vertebrae, the pelvis, and both proximal femurs. As seen here, these lesions typically have low signal intensity on T1-weighted images and bright signal intensity on fat-saturated proton-density-weighted images. (d) Close-up view from a coronal fat-saturated intermediate-density-weighted MR image (2,000/15) reveals lesions that have increased signal intensity and form a convex border with the adjacent marrow fat (arrow). (e, f) Coronal T1-weighted (500/8) (e) and fat-saturated intermediate-density-weighted (2,000/15) (f) MR images obtained 7 months later show nearly complete resolution of the previously detected intramedullary lesions. Faint low-signal-intensity ghosts of the lesions persist (arrow in f). The patient did not undergo treatment for sarcoidosis.

View larger version (144K): [in a new window]   Figure 4b. Large bone sarcoidosis in a 48-year-old man with left hip pain. (a) Anteroposterior radiograph shows the normal pelvis. (b, c) Coronal T1-weighted (450/8) (b) and fat-saturated intermediate-density-weighted (2,000/15) (c) MR images demonstrate numerous discrete round lesions within the lumbar vertebrae, the pelvis, and both proximal femurs. As seen here, these lesions typically have low signal intensity on T1-weighted images and bright signal intensity on fat-saturated proton-density-weighted images. (d) Close-up view from a coronal fat-saturated intermediate-density-weighted MR image (2,000/15) reveals lesions that have increased signal intensity and form a convex border with the adjacent marrow fat (arrow). (e, f) Coronal T1-weighted (500/8) (e) and fat-saturated intermediate-density-weighted (2,000/15) (f) MR images obtained 7 months later show nearly complete resolution of the previously detected intramedullary lesions. Faint low-signal-intensity ghosts of the lesions persist (arrow in f). The patient did not undergo treatment for sarcoidosis.

View larger version (131K): [in a new window]   Figure 4c. Large bone sarcoidosis in a 48-year-old man with left hip pain. (a) Anteroposterior radiograph shows the normal pelvis. (b, c) Coronal T1-weighted (450/8) (b) and fat-saturated intermediate-density-weighted (2,000/15) (c) MR images demonstrate numerous discrete round lesions within the lumbar vertebrae, the pelvis, and both proximal femurs. As seen here, these lesions typically have low signal intensity on T1-weighted images and bright signal intensity on fat-saturated proton-density-weighted images. (d) Close-up view from a coronal fat-saturated intermediate-density-weighted MR image (2,000/15) reveals lesions that have increased signal intensity and form a convex border with the adjacent marrow fat (arrow). (e, f) Coronal T1-weighted (500/8) (e) and fat-saturated intermediate-density-weighted (2,000/15) (f) MR images obtained 7 months later show nearly complete resolution of the previously detected intramedullary lesions. Faint low-signal-intensity ghosts of the lesions persist (arrow in f). The patient did not undergo treatment for sarcoidosis.

View larger version (119K): [in a new window]   Figure 4d. Large bone sarcoidosis in a 48-year-old man with left hip pain. (a) Anteroposterior radiograph shows the normal pelvis. (b, c) Coronal T1-weighted (450/8) (b) and fat-saturated intermediate-density-weighted (2,000/15) (c) MR images demonstrate numerous discrete round lesions within the lumbar vertebrae, the pelvis, and both proximal femurs. As seen here, these lesions typically have low signal intensity on T1-weighted images and bright signal intensity on fat-saturated proton-density-weighted images. (d) Close-up view from a coronal fat-saturated intermediate-density-weighted MR image (2,000/15) reveals lesions that have increased signal intensity and form a convex border with the adjacent marrow fat (arrow). (e, f) Coronal T1-weighted (500/8) (e) and fat-saturated intermediate-density-weighted (2,000/15) (f) MR images obtained 7 months later show nearly complete resolution of the previously detected intramedullary lesions. Faint low-signal-intensity ghosts of the lesions persist (arrow in f). The patient did not undergo treatment for sarcoidosis.

View larger version (136K): [in a new window]   Figure 4e. Large bone sarcoidosis in a 48-year-old man with left hip pain. (a) Anteroposterior radiograph shows the normal pelvis. (b, c) Coronal T1-weighted (450/8) (b) and fat-saturated intermediate-density-weighted (2,000/15) (c) MR images demonstrate numerous discrete round lesions within the lumbar vertebrae, the pelvis, and both proximal femurs. As seen here, these lesions typically have low signal intensity on T1-weighted images and bright signal intensity on fat-saturated proton-density-weighted images. (d) Close-up view from a coronal fat-saturated intermediate-density-weighted MR image (2,000/15) reveals lesions that have increased signal intensity and form a convex border with the adjacent marrow fat (arrow). (e, f) Coronal T1-weighted (500/8) (e) and fat-saturated intermediate-density-weighted (2,000/15) (f) MR images obtained 7 months later show nearly complete resolution of the previously detected intramedullary lesions. Faint low-signal-intensity ghosts of the lesions persist (arrow in f). The patient did not undergo treatment for sarcoidosis.

View larger version (131K): [in a new window]   Figure 4f. Large bone sarcoidosis in a 48-year-old man with left hip pain. (a) Anteroposterior radiograph shows the normal pelvis. (b, c) Coronal T1-weighted (450/8) (b) and fat-saturated intermediate-density-weighted (2,000/15) (c) MR images demonstrate numerous discrete round lesions within the lumbar vertebrae, the pelvis, and both proximal femurs. As seen here, these lesions typically have low signal intensity on T1-weighted images and bright signal intensity on fat-saturated proton-density-weighted images. (d) Close-up view from a coronal fat-saturated intermediate-density-weighted MR image (2,000/15) reveals lesions that have increased signal intensity and form a convex border with the adjacent marrow fat (arrow). (e, f) Coronal T1-weighted (500/8) (e) and fat-saturated intermediate-density-weighted (2,000/15) (f) MR images obtained 7 months later show nearly complete resolution of the previously detected intramedullary lesions. Faint low-signal-intensity ghosts of the lesions persist (arrow in f). The patient did not undergo treatment for sarcoidosis.

View larger version (187K): [in a new window]   Figure 5a. Large bone sarcoidosis in a 53-year-old woman with bilateral heel pain. The patient’s medical history was unknown. (a) Sagittal T1-weighted MR image (450/10) demonstrates a round, low-signal-intensity lesion that involves the plantar aspect of the calcaneus. Biopsy of a lesion of the contralateral calcaneus (not shown) revealed noncaseating granulomas and led to further clinical evaluation, results of which confirmed systemic sarcoidosis. (b) Lateral radiograph of the ankle reveals a faint area of increased opacity in the area of the lesion seen at MR imaging, with no radiographic evidence of trabecular or cortical disruption. The radiograph was interpreted as normal. (c) Sagittal fat-saturated T1-weighted MR image (650/8) obtained after the intravenous administration of gadopentetate dimeglumine shows an indistinctly marginated area of enhancement with a central area of spared marrow in the contralateral calcaneus (arrow).

View larger version (156K): [in a new window]   Figure 5b. Large bone sarcoidosis in a 53-year-old woman with bilateral heel pain. The patient’s medical history was unknown. (a) Sagittal T1-weighted MR image (450/10) demonstrates a round, low-signal-intensity lesion that involves the plantar aspect of the calcaneus. Biopsy of a lesion of the contralateral calcaneus (not shown) revealed noncaseating granulomas and led to further clinical evaluation, results of which confirmed systemic sarcoidosis. (b) Lateral radiograph of the ankle reveals a faint area of increased opacity in the area of the lesion seen at MR imaging, with no radiographic evidence of trabecular or cortical disruption. The radiograph was interpreted as normal. (c) Sagittal fat-saturated T1-weighted MR image (650/8) obtained after the intravenous administration of gadopentetate dimeglumine shows an indistinctly marginated area of enhancement with a central area of spared marrow in the contralateral calcaneus (arrow).

View larger version (128K): [in a new window]   Figure 5c. Large bone sarcoidosis in a 53-year-old woman with bilateral heel pain. The patient’s medical history was unknown. (a) Sagittal T1-weighted MR image (450/10) demonstrates a round, low-signal-intensity lesion that involves the plantar aspect of the calcaneus. Biopsy of a lesion of the contralateral calcaneus (not shown) revealed noncaseating granulomas and led to further clinical evaluation, results of which confirmed systemic sarcoidosis. (b) Lateral radiograph of the ankle reveals a faint area of increased opacity in the area of the lesion seen at MR imaging, with no radiographic evidence of trabecular or cortical disruption. The radiograph was interpreted as normal. (c) Sagittal fat-saturated T1-weighted MR image (650/8) obtained after the intravenous administration of gadopentetate dimeglumine shows an indistinctly marginated area of enhancement with a central area of spared marrow in the contralateral calcaneus (arrow).

View larger version (139K): [in a new window]   Figure 6. Large bone sarcoidosis in a 54-year-old woman. Coronal T1-weighted MR image (450/14) shows an irregular area of decreased signal intensity in the left iliac bone (arrows). The increased signal intensity centrally within the lesion represents fat. Biopsy of the lesion revealed noncaseating granulomas.

View larger version (137K): [in a new window]   Figure 7. Large bone sarcoidosis in a 41-year-old man. Coronal fat-saturated intermediate-density-weighted MR image (3,899/28) shows a diffuse stippled pattern of abnormal signal intensity throughout the marrow of the pelvic bones. Biopsy was positive for noncaseating granulomas.

View larger version (97K): [in a new window]   Figure 8a. Calvarial lesion in a 34-year-old woman with sarcoidosis. Bone scintigraphy showed radiotracer uptake in the left temporal bone. (a) Axial CT scan shows a subtle expansile lesion of the left temporal bone with cortical thinning (arrow). (b) Axial T1-weighted MR image (450/8) shows low-signal-intensity intramedullary infiltrate in the left temporal bone (arrow). The lesion is more conspicuous at CT. No extraosseous mass was demonstrated. The patient declined to undergo biopsy.

View larger version (119K): [in a new window]   Figure 8b. Calvarial lesion in a 34-year-old woman with sarcoidosis. Bone scintigraphy showed radiotracer uptake in the left temporal bone. (a) Axial CT scan shows a subtle expansile lesion of the left temporal bone with cortical thinning (arrow). (b) Axial T1-weighted MR image (450/8) shows low-signal-intensity intramedullary infiltrate in the left temporal bone (arrow). The lesion is more conspicuous at CT. No extraosseous mass was demonstrated. The patient declined to undergo biopsy.

View larger version (103K): [in a new window]   Figure 9. Sarcoidal arthropathy in a 52-year-old woman. On an axial contrast-enhanced fat-saturated T1-weighted MR image (500/10) of the distal forearm, the extensor tendon sheath is distended with fluid and shows synovial enhancement. Synovial biopsy revealed noncaseating granulomas.

View larger version (111K): [in a new window]   Figure 10. Presumed sarcoidal arthropathy in a 34-year-old woman with extensive bone involvement of the hands and feet. Axial intermediate-density-weighted MR image (4,016/15) of the left ankle demonstrates tenosynovitis of the peroneal tendon sheath (left arrow) and tendonosis of the Achilles tendon (right arrow). A subtle focus of abnormal marrow signal intensity is noted in the distal fibula.

View larger version (70K): [in a new window]   Figure 11. Nodular sarcoidal myopathy in a 51-year-old woman with a 2-year history of sarcoidosis and painful nodules in both legs. Axial fat-saturated T1-weighted MR image (616/9) through the midcalf obtained after intravenous administration of gadopentetate dimeglumine shows multiple intramuscular lesions with thick rimlike enhancement and central low signal intensity (arrows). Biopsy revealed noncaseating granulomas.

View larger version (166K): [in a new window]   Figure 12. Nonspecific myopathy in a woman with leg weakness who had undergone long-term corticosteroid treatment for presumed sarcoidal myopathy. Prior muscle biopsy had demonstrated noncaseating granulomas. Coronal T1-weighted MR image (716/12) of the thighs demonstrates extensive fatty replacement of the thigh muscles.

View larger version (127K): [in a new window]   Figure 13. Sarcoidal myopathy in a 38-year-old man with thigh swelling. Axial T1-weighted MR image (450/13) demonstrates focal subcutaneous reticulation with low signal intensity at the anterolateral aspect of the midthigh (arrow). A study performed 10 months earlier had yielded the same finding. Biopsy was positive for noncaseating granulomas.

View larger version (114K): [in a new window]   Figure 14. Sarcoidal mass in a patient with swelling over the left temporal area. Axial fat-saturated T1-weighted MR image (416/8) of the head shows a solid enhancing mass over the left calvaria and insinuating itself into the temporal muscle (arrow). Biopsy of an adjacent ocular mass (not shown) was positive for noncaseating granulomas.