Case Presentation: A 72-year-old male with hypertension, chronic kidney disease, and nephrolithiasis presented with six months of progressive weakness, unintentional weight loss, and fatigue. He had recurrent hypercalcemia, pancytopenia and recently diagnosed cirrhosis of undetermined etiology. The patient had three hospitalizations in the preceding six months for failure to thrive and hypercalcemia responsive to intravenous hydration. A prior bone marrow biopsy (BMB) revealed hypercellular marrow without evidence of dyspoiesis and showed a single focal poorly-formed granuloma. Prior chest radiographs had not shown evidence of hilar lymphadenopathy. At the time of admission, the patient described acute worsening of his generalized weakness, new confusion, additional weight loss, and one week of fevers. Lab work showed an elevated ionized calcium (6.61 mg/dL [4.6-5.3]), low parathyroid hormone (< 6.3 pg/mL [14-72]), parathyroid hormone-related protein within normal limits (0.9 pmol/L), low 25-hydroxy Vitamin D 10.4 ng/ml [30-100], elevated 1,25-dihydroxy Vitamin D (88 pg/ml [20-79]) and an elevated angiotensin-converting enzyme level (225 U/L [19-123]). Repeat BMB exhibited a nonspecific T-lymphoid infiltrate and hypercellular marrow. A positron emission tomography-computed tomography (PET-CT) revealed hypermetabolic adenopathy of the chest and abdomen as well as hypermetabolic lesions involving the bone, liver and lungs. A subsequent mediastinal lymph node biopsy demonstrated a significant number of noncaseating hyalinized granulomas. Elderly-onset sarcoidosis (EOS) with multiorgan involvement was diagnosed. Initial treatment with high dose prednisone and hydroxychloroquine resulted in improvement of symptoms, calcium level and pancytopenia at one-month follow-up.
Discussion: EOS, defined as sarcoidosis occurring after age 65, poses diagnostic challenges due to atypical presentations and its insidious clinical course. EOS is rare and poorly characterized in the literature. Nonspecific constitutional symptoms and extrapulmonary manifestations are more common in EOS compared to young-onset sarcoidosis (YOS). This case highlights the diagnostic complexities of EOS, often requiring stepwise hospital workup to rule out infectious or malignant etiologies, which are often high on the differential due to accumulated risk factors and comorbidities. The patient’s failure to thrive, along with PET-CT findings, raised concern for a widely metastatic malignancy. The mediastinal biopsy was crucial in securing the diagnosis and steering the course to effective treatment. The approach to treating EOS is often similar to YOS. In contrast, however, advanced age and increased prevalence of comorbidities complicate the management of EOS. In particular, there is an increased risk of adverse effects from immunosuppressive therapy.
Conclusions: EOS exhibits distinct clinical features compared to YOS, requiring hospitalists to maintain a high level of clinical suspicion for timely diagnosis. The overlap of EOS features with malignancies or infections underscores the need for thorough diagnostic evaluation, including tissue biopsy.