Multiple myeloma with lacrimal gland amyloidosis and sarcoidosis

Our patient, a 46-year-old black woman, diagnosed with pulmonary sarcoidosis at bronchoscopy but without significant symptomatology for 14 years presented to her primary physician with marked bilateral upper eyelid swelling, conjunctival erythema, and dry eyes. Initial laboratory studies including chemistries, urinalysis, and complete blood count were normal. She was treated with topical ophthalmic steroids, because her symptoms and physical findings were thought to be extrapulmonary manifestations of sarcoidosis. Despite several weeks of treatment, her symptoms and physical findings persisted, and she was referred to an ophthalmologist. A computed tomography (CT) scan of the orbits was obtained and confirmed extensive bilateral enlargement of the lacrimal glands. The ophthalmologist concurred with the presumptive diagnosis of orbital sarcoidosis and continued topical treatment. Because of the patient's history of sarcoidosis, although she stated that she had no pulmonary symptoms, she was referred to pulmonary medicine for further clinical evaluation. She underwent radiography and high-resolution chest CT that showed patchy areas of central and peripheral honeycombing fibrosis in the upper lobes of both lungs without hilar adenopathy. These findings were consistent with radiographic Stage IV pulmonary sarcoidosis with multifocal fibrotic changes. Spirometry was normal without restrictive or obstructive abnormalities. Serum nuclear antibodies for Wegener granulomatosis were also negative.