Bone Involvement in Sarcoidosis: Insights from a Multicenter Italian Cohort

Tommaso Pianigiani; Elisa Bianchi; Giulio Natalello; Roberto Barone; Francesca  Aloe; Bianca  Boncompagni; Carla Caffarelli; Lucia  Vietri; Maria Antonietta Mazzei; Elena  Bargagli; Alberto  Papi; Luca  Richeldi; Fabiano Di Marco; Paolo Cameli

doi:10.36141/svdld.2026.17720

Authors

Tommaso Pianigiani UOC Respiratory Diseases and Lung Transplant, University of Siena - Siena (Italy)
Elisa Bianchi 2Department of Health Sciences, University of Milan, Respiratory Unit ASST - Papa Giovanni XXIII Hospital, Bergamo, Italy
Giulio Natalello Department of Medical Sciences, Surgery and Neuroscience, Respiratory Disease and Lung Transplant Unit, University of Siena, Italy
Roberto Barone 3Faculty of Medicine and Surgery, Catholic University of Sacred Heart, Rome
Francesca Aloe 4Department of Respiratory Medicine, University of Ferrara Medical School, Ferrara
Bianca Boncompagni 2Department of Health Sciences, University of Milan, Respiratory Unit ASST - Papa Giovanni XXIII Hospital, Bergamo, Italy
Carla Caffarelli 6Section of Internal Medicine, Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy.
Lucia Vietri 4Department of Respiratory Medicine, University of Ferrara Medical School, Ferrara
Maria Antonietta Mazzei 5Unit of Diagnostic Imaging, Department of Medical, Surgical and Neurosciences and of Radiological Sciences, University of Siena, Azienda Ospedaliero-Universitaria Senese, Siena, Italy
Elena Bargagli 1Department of Medical Sciences, Surgery and Neuroscience, Respiratory Disease and Lung Transplant Unit, University of Siena, Italy
Alberto Papi 4Department of Respiratory Medicine, University of Ferrara Medical School, Ferrara
Luca Richeldi 3Faculty of Medicine and Surgery, Catholic University of Sacred Heart, Rome
Fabiano Di Marco 2Department of Health Sciences, University of Milan, Respiratory Unit ASST - Papa Giovanni XXIII Hospital, Bergamo, Italy
Paolo Cameli 1Department of Medical Sciences, Surgery and Neuroscience, Respiratory Disease and Lung Transplant Unit, University of Siena, Italy

Keywords:

sarcoidosis, bone sarcoidosis, Hepatosplenic sarcoidosis, Multicenter study, Bone involvement

Abstract

Background: Sarcoidosis is a multisystemic granulomatous disease that can involve the skeletal system, although bone manifestations are considered relatively uncommon and often underdiagnosed.

Objectives: To describe the prevalence, clinical characteristics, and treatment outcomes of bone involvement in a large multicenter Italian cohort of patients with sarcoidosis.

Methods: This retrospective, two-center observational study included 867 patients with histologically confirmed sarcoidosis followed at two Italian referral centers (2018–2025). Bone localization was identified by imaging (PET/CT, MRI, X-ray) and/or biopsy. Clinical, functional, laboratory, and therapeutic data were collected.

Results: Bone involvement was found in 46 patients (5.3%), predominantly women (58.7%), with mean age at diagnosis of 49.7 ± 12.2 years. Osseous lesions were most frequently localized in the axial skeleton, particularly pelvis (54.3%) and vertebrae (52.2%). Bone sarcoidosis was significantly associated with extra-thoracic lymphadenopathy, hepatic, and splenic involvement (p < 0.001), reflecting a pattern of clustered multi-organ disease. Osteoporosis and osteopenia were present in 15.2% and 13.0% of cases, respectively. Corticosteroid monotherapy was the most common initial treatment (56.5%), while 30.4% received combination therapy with csDMARDs or biologics. At one-year PET/CT re-evaluation, 56.5% showed a reduction of SUV at bone sites, with no significant correlation between therapeutic regimen and metabolic response.

Conclusions: Bone involvement in sarcoidosis, though relatively rare, represents a clinically relevant phenotype strongly associated with hepatosplenic and lymphatic disease and characterized by a preferential axial skeleton localization. Recognition of this pattern is essential for diagnosis and management. Given the retrospective design and the limited follow-up sample, these findings should be interpreted with caution. Close radiological monitoring and tailored therapeutic strategies are warranted to improve outcomes.

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