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A and B: Chest computed tomography images showing hilar lymphadenopathy (Case 1).
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Liver biopsy showing characteristic granulomatous lesion of sarcoidosis (Case 1).
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B). Both hepatic lesions and abdominal lymph nodes were biopsied and revealed non-caseating sarcoid granulomas (Fig. 2).
Reticulin stain showing grade III fibrosis (Case 1).
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Bone marrow biopsy revealed evidence of myelofibrosis (Fig. 3), with immunohistochemistry showing normal CD34 pattern, occasional scattered CD20 positive cells, marked increase in CD68 positive macrophages, reticulin showing heterogeneous areas of fibrosis grade III, cytokeratin was negative which excluded secondary epithelial tumors, myeloperoxidase was positive with normal distribution, and Ziehl-Neelsen stain was negative.
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A. Five megakaryocytes showing emperipolesis and some show nuclear atypia (bone marrow biopsy). B. Extensive emperipolesis in a megakaryocyte (bone marrow aspirate) (Case 2).
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Bone marrow aspirate and biopsy demonstrated normal cellular bone marrow with increased megakaryocytes and evidence of emperipolesis (Fig. 4A and B); hence, was diagnosed with immune thrombocytopenic purpura (ITP) with megakaryocytic emperipolesis associated with sarcoidosis.
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Brain Magnetic Resonance Imaging showing leptomeningeal enhancement (Case 3).
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Brain magnetic resonance imaging (MRI) with and without contrast demonstrated leptomeningeal thickening (Fig. 5).
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A, B, and C: : Normal brain magnetic resonance imaging (Case 4).
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Brain MRI was normal with no meningeal thickening, space occupying lesions, or dilated ventricles (hydrocephalic changes) (Fig. 6A, B, and C).