Clinical and radiological resolution of vertebral sarcoidosis mimicking metastatic disease

•Vertebral sarcoidosis cannot be certainly differentiated from metastatic disease based on imaging only.•Vertebral sarcoidosis lesions are mostly focal osteolytic, sclerotic, or combined.•Osseous sarcoidosis may have an increased uptake on 18F-FDG-PETand may guide to false-positive results.•Accurate diagnosis is only attainable by histopathological verification of the lesions.•Corticosteroids are the first line of treatment. Sarcoidosis is a disease that exhibits extreme heterogeneous clinical manifestations. Bone involvement in sarcoidosis is rare (1%-13%), and involvement of the vertebrae is even rarer. Usually, it is a diagnosis of exclusion with nonspecific characteristics in imaging. A 35-year-old male, who has no significant medical history£. He came to clinical examination for lower back and associated bilateral lower extremity pain. Magnetic resonance imaging (MRI) was performed to exclude disc-related pathology. It demonstrates left paramedian lumbar disc herniation at L4–L5 level. Multiple small enhancing lesions throughout the lumbar vertebrae were discovered as an incidental finding. An 18F-labeled fluorodeoxyglucose was performed to evaluate for metastatic disease that shows hypermetabolic apical right nodule of the lung parenchyma with multiple mediastinal and right iliac external adenopathy. Increased uptake throughout the lumbar vertebral lesions was also seen. A CT-guided biopsy of the right apical lung nodule and one of the vertebral lesions (L3) revealed noncaseating granulomas consistent with sarcoidosis. We introduce steroid treatment with favorable evolution of vertebral lesions. Vertebral sarcoidosis cannot be certainly differentiated from metastatic disease based on imaging only. Accurate diagnosis is only attainable by histopathological verification of the lesions.