SummarySarcoidosis is an autoimmune granulomatous disease that can affect any organ system in the body. Ocular and orbital manifestations are relatively common. Osseous involvement is rare and usually involves bones of the appendicular skeleton. We present an unusual case of an erosive sarcoid granuloma in a 48-year-old woman that involved the orbital apex. This case highlights diagnosis, treatment, and the importance of full systemic workup to determine the extent of the disease. Case ReportA 48-year-old, African American woman with a past medical history significant for nonischemic cardiomyopathy presented to the cardiology clinic at the University of Kansas Hospital for follow-up examination. She complained of a 1-week history of parieto-occipital headache and progressive vision loss in the right eye. She denied eye pain, flashes/floaters, diplopia, or changes in vision in her left eye. Neurology was consulted, and the patient was transferred to the emergency department for a stroke workup. Computed tomography (CT) of the head without contrast showed no abnormalities.On ophthalmological examination, her best-corrected visual acuity was 20/30 in the right eye and 20/20 in the left eye, with no afferent pupillary defect (APD). There was a mild temporal restriction on confrontation visual field testing in the right eye; the visual field was full in the left eye. The dilated posterior segment appeared unremarkable in each eye. The patient was discharged with a diagnosis of an atypical migraine and was instructed to follow-up at the outpatient ophthalmology clinic the following week.Two days later, the patient presented to the emergency department with worsening of her symptoms. On examination, visual acuity in the right eye was hand motions; in the left eye, 20/20. There was a new APD in the right eye. Intraocular pressure (IOP) by Tono-Pen (Reichert Technologies, Depew, NY) was 14 mm Hg in the right eye and 13 mm Hg in the left eye. Visual field by confrontation was restricted in all quadrants except superotemporally in the right eye and full in the left eye. Dilated fundus examination again revealed an unremarkableappearing optic nerve head, macula, vessels and periphery in each eye.With no abnormalities seen on the dilated fundus examination, workup for a posterior optic neuropathy was initiated. A CT of the brain without contrast was repeated, and no abnormalities were noted. A CT of the orbits without contrast showed an abnormal soft tissue lesion with an aggressive erosive process involving the posterior right orbit and ethmoid sinus (Figure 1). CT of the chest without contrast showed mediastinal and bilateral hilar lymphadenopathy as well as multiple bilateral lung nodules concerning for sarcoidosis or lymphoma ( Figure 2). Positron emission tomography scan showed increased fluorodeoxyglucose uptake within the region of the right ethmoid sinus and metabolically active supraclavicular, mediastinal, hilar, periportal, and inguinal lymphadenopathy with diffuse increased uptake of the spleen. Lumbar puncture ...
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