Sarcoidosis presenting as fulminant bilateral multifocal choroiditis

To report a case of fulminant bilateral multifocal choroiditis as the presenting manifestation of sarcoidosis despite normal serum angiotensin-converting enzyme (ACE) and unremarkable thoracic imaging.

An immunocompetent 32-year-old man was admitted with a systemic inflammatory illness and peripheral lymphadenopathy. Given the acute systemic symptoms and recent international travel to Southeast Asia, an infectious cause was initially suspected. Two days after admission, he developed rapidly progressive bilateral central scotomas, floaters, and photophobia. Examination demonstrated bilateral granulomatous keratic precipitates, anterior chamber and vitreous inflammation, and multifocal yellowish deep retinal lesions with indistinct margins involving the posterior pole and midperiphery. Fundus autofluorescence demonstrated hypoautofluorescent lesions with surrounding hyperautofluorescence, and optical coherence tomography (OCT) showed retinal thickening with outer retinal disorganization, subretinal and intraretinal fluid, retinal pigment epithelium (RPE) hyperreflectivity and elevation, and choroidal thickening. Infectious investigations, neuroimaging, serum ACE, and thoracic imaging were unrevealing. Although vision deteriorated despite intensive topical therapy, it improved rapidly after high-dose systemic corticosteroids. Excisional biopsy of a palpable inguinal lymph node showed well-formed non-necrotizing granulomas with negative fungal and mycobacterial stains, findings considered in keeping with sarcoidosis. Methotrexate was commenced as steroid-sparing therapy. Quiescence was achieved within three weeks, and visual acuity recovered to 20/20 bilaterally by two months.

Sarcoidosis may present as fulminant bilateral multifocal choroiditis even when serum ACE and thoracic imaging are normal. Careful general examination for peripheral lymphadenopathy, including inguinal nodes, may help identify an accessible extrathoracic biopsy target, facilitating timely tissue confirmation and early immunosuppression.