Bladder sarcoidosis presenting with clot-forming gross hematuria: a case report

Abstract Brief introduction Direct bladder involvement by sarcoidosis is exceptionally rare and may mimic urothelial malignancy or infectious granulomatous cystitis. We report a case presenting with clot-forming gross hematuria in which the integrated clinical and pathological findings favored bladder sarcoidosis and the cystoscopic response to systemic glucocorticoids was objectively documented. Case summary A 60-year-old African American man with biopsy-proven pulmonary sarcoidosis, off sarcoidosis-directed therapy since 2016, presented in February 2018 with two weeks of painless gross hematuria progressing to clot passage. Cystoscopy showed multifocal smooth, broad-based, sessile, nonpapillary bladder lesions. The contemporaneous bladder-biopsy pathology report documented well-formed non-necrotizing epithelioid granulomas without urothelial atypia or malignancy in the sampled tissue; Ziehl-Neelsen and Grocott-Gomori methenamine silver stains were negative. CT urography, urine cytology, mycobacterial or fungal tissue cultures, and molecular testing were not performed, limiting definitive exclusion of synchronous upper-tract malignancy and infection. Prednisone 20 mg/day was restarted and tapered over approximately six months. Gross hematuria ceased by day 12, urinalysis showed no hematuria at three weeks, and cystoscopy at four months demonstrated complete lesion resolution. No recurrent gross hematuria or clot passage was documented during 12 months of clinical follow-up. Conclusion Bladder sarcoidosis should be considered in patients with established sarcoidosis and granulomatous bladder lesions, but diagnosis requires clinicopathological correlation and careful exclusion of competing causes. Clinical and cystoscopic response to glucocorticoids is supportive rather than diagnostic and does not replace complete hematuria evaluation or appropriate microbiological assessment.