Background: Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Ocular involvement has been reported in about 25% of patients (1). Band keratopathy is rare in sarcoidosis.
Patient: A 31 year-old clerk presented to our clinic with a 10 months' history of foreign body sensation OU. Visual acuity was OD1.2, OS 1.0. Intraocular pressure was 10 mm Hg OU. We found a moderate band keratopathy OU (Fig. 1a, 1b). The rest of the ocular exam was unremarkable. 10 months before, the patient had experienced symmetrical swelling of his large joints and his creatinine and calcium levels had been elevated at that time. Therefore, we referred the patient to the internist to rule out primary hyperparathyroidism (2). The differential diagnosis included myeloma, paraneoplasia and sarcoidosis (3). The general medical examination was unremarkable. Calcium (2.5 mmol/l), creatinine (2.0 mg/dl) and ACE-levels (177 U/ml) were elevated, parathormone (< 1.4 pg/ml) was low. The chest x-ray showed reticular, small-nodular changes of both lungs. Pulmonary function tests and the bronchial mucosa were normal. The CD4/CD8-ratio was markedly elevated. Ultrasonography of the kidneys suggested nephrocalcinosis. This was confirmed by kidney biopsy. Histologic findings were consistent with the diagnosis of sarcoidosis. After initial symptomatic reduction of calcium levels by forced diuresis, calcium and creatinine levels were lowered by administration of 60 mg prednisolone daily. Six months after presenting to our clinic the patient is well on low-dose steroids and his calcium levels are normal.
Discussion: Primary hyperthyroidism was ruled out by low PTH-levels. Because of clinical, serologic and radiologic findings suggestive of sarcoidosis, bronchoscopy with bronchoalveolar lavage was performed. Since the CD 4/CD 8-ratio was increased, a kidney biopsy was performed which confirmed the diagnosis.