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Andrew H. Kalajian, MD; Jonathan R. Van Meter, MS; Jeffrey P. Callen, MD

Arch Dermatol. 2009;145(8):905-909.

Background  Sarcoidosis is a multisystem granulomatous disease that may involve the bone marrow, with resultant fever, anemia, and leukopenia. Although generally effective in treating the clinical manifestations of bone marrow sarcoidosis, systemic corticosteroids are not warranted for long-term therapy because of their well-known adverse effects. Therefore, alternative corticosteroid-sparing therapeutic regimens are desired.

Observations  A 41-year-old man sought treatment for cutaneous and bone marrow sarcoidosis resulting in fatigue, anemia, and leukopenia refractory to conventional therapies and mycophenolate mofetil. We initiated combination immunosuppressive therapy with methotrexate sodium and mycophenolate mofetil, which resulted in a safe and prolonged quiescence of cutaneous disease and resolution of anemia and leukopenia throughout a 34-month follow-up period.

Conclusions  We present this case to highlight the growing body of evidence supporting combination immunosuppressive therapy to treat refractory sarcoidosis. In our patient, sarcoidal bone marrow involvement responded dramatically to a combined regimen of methotrexate and mycophenolate mofetil with no significant adverse effects, despite previously having been refractory to conventional agents and mycophenolate mofetil alone. This report provides evidence that combination immunosuppressive therapy is a potential treatment of refractory bone marrow sarcoidosis and highlights important issues about combined immunosuppressive therapy.

Author Affiliations: Division of Dermatology, Department of Medicine (Drs Kalajian and Callen), and School of Medicine (Mr Van Meter), University of Louisville, Louisville, Kentucky.

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