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Lymph node and lung biopsy confirmed non-necrotising granulomatous inflammation while a BAL showed scanty growth of Cryptococcus neoformans and moderate growth of <jats:italic>Staphylococcus aureus<\/jats:italic>. The patient received intravenous ceftriaxone and had a good response to treatment. She also completed 3\u2009months of oral fluconazole. Although a diagnosis of sarcoidosis was considered most likely, the patient was not initially started on systemic corticosteroids due to concern around possible infection and initial response to antimicrobials. However, her exercise tolerance gradually deteriorated. A craniofacial CT revealed multiple lytic lesions involving the skull and visualised cervical spine. Biopsy of a clivus lesion revealed non-necrotising granulomatous inflammation while fungal cultures and histopathological stains were negative. The patient was diagnosed with widespread sarcoidosis and she was initiated on prednisolone and methotrexate which led to marked clinical and radiological improvement.<\/jats:p>","DOI":"10.1136\/bcr-2021-242685","type":"journal-article","created":{"date-parts":[[2021,6,9]],"date-time":"2021-06-09T11:48:23Z","timestamp":1623239303000},"page":"e242685","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":3,"title":["Case report of osteolytic lesions in a patient with multisystem granulomatous disease"],"prefix":"10.1136","volume":"14","author":[{"given":"Henco","family":"Nel","sequence":"first","affiliation":[{"name":"Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Brad","family":"Davis","sequence":"additional","affiliation":[{"name":"SKG Radiology, St John of God Subiaco, Perth, Western Australia, 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