Case of Sarcoidosis Relapse After 9 Years Illustrates Need for More Knowledge

Researchers at Jichi Medical University in Japan reported a case of sarcoidosis relapse in a woman who developed renal dysfunction, high calcium levels, as well as kidney and urethral stones.

The report, “Renal Failure Found during the Follow-up of Sarcoidosis: The Relevance of a Delay in the Diagnosis of Concurrent Hypercalcemia,” published in the journal Internal Medicine, illustrates the difficulties clinicians meet in the long-term monitoring of sarcoidosis patients.

The woman was 67 years old when admitted to the hospital with an increasingly worse kidney function. Nine years earlier she had been diagnosed with sarcoidosis in the eye, and although she had enlarged lymph nodes in both lungs, she had no evidence of lung disease.

Two years earlier, doctors had noted that her calcium levels were abnormally high, but she had no symptoms. Then her calcium levels rose even further and she started to lose her appetite. Tests revealed that her lymph nodes were enlarged in several places in the body and she had abnormally high levels of the enzyme ACE — a typical finding in sarcoidosis patients.

A kidney biopsy revealed inflammation and fibrosis, but researchers saw no deposits of immune cells or granulomas. Considering all the clinical tests, physicians diagnosed the case as a relapse of sarcoidosis complicated by high calcium levels.

The woman was treated with the corticosteroid prednisolone and other drugs to lower the calcium levels, which slowly started to decrease. Her renal function, however, was slower to improve, and after 14 months, the woman was still dependent on corticosteroid treatment.

The lack of granulomas in the woman’s kidney biopsy made the diagnosis more difficult, but considering other findings, the researchers argue that sarcoidosis was the most likely diagnosis. They also noted that it is rare for sarcoidosis to relapse once it has been completely eradicated by previous treatment, and in the rare cases the disease does relapse, it often comes back within months after treatment is stopped.

This case, researchers believe, illustrates the difficulty in monitoring patients for a long time. Also, the tracking of the woman’s health decline was made more difficult since the physicians did not have access to health records from earlier years, which might have allowed them to detect the disease at an earlier stage.

Collecting more data on this type of relapse, particularly involving high calcium states, might improve both diagnosis and treatment for future patients.