Sarcoid dactylitis in black South African patients

Rare case of Lyme borreliosis in a patient presenting with dactylitis and skin rash

An immunocompetent male in his 70s was diagnosed with psoriatic arthritis based on dactylitis, onycholysis of the nails and scalp psoriasis. He was treated with corticosteroids, methotrexate and local corticosteroid injections without improvements in his symptoms. When tumor necrosis factor-alpha inhibitor treatment was introduced, the symptoms worsened and dactylitis of all digits and a bluish-red rash were observed on the extensor side of the left hand and arm. At this point, a skin biopsy was performed showing histopathological changes compatible with Lyme borreliosis and serum contained IgG antibodies against Borrelia burgdorferi It was concluded that he was suffering from acrodermatitis chronica atrophicans (ACA) and Lyme dactylitis. Ten days of phenoxymethylpenicillin treatment was initiated, and after 2 weeks, the dactylitis and ACA had regressed substantially. After 6 months, both had resolved. This case emphasises the need for clinical reassessment, when treatment is not effective.

Sarcoidosis: a comprehensive review and update for the dermatologist: part I. Cutaneous disease

Sarcoidosis is a common systemic, noncaseating granulomatous disease of unknown etiology. The development of sarcoidosis has been associated with a number of environmental factors and genes. Cutaneous sarcoidosis, the "great imitator," can baffle clinicians because of its diverse manifestations and its ability to resemble both common and rare cutaneous diseases. Depending on the type, location, and distribution of the lesions, treatment can prevent functional impairment, symptomatic distress, scarring, and disfigurement. Numerous therapeutic options are available for the treatment of cutaneous sarcoidosis, but there are few well designed trials to guide practitioners on evidence-based, best practice management. In part I, we review the current knowledge and advances in the epidemiology, etiology, pathogenesis, and genetics of sarcoidosis, discuss the heterogeneous manifestations of cutaneous sarcoidosis, and provide a guide for treatment of cutaneous sarcoidosis.

Magnetic resonance imaging of inflammatory arthropathies of peripheral joints

As the treatment of inflammatory arthropathies has advanced with new therapies that can slow or even halt the development of disabling disease, early and accurate diagnosis has become imperative. Magnetic resonance (MR) imaging has proved to be very sensitive in the detection of erosions, but more importantly, it can demonstrate pre-erosive changes. Detection of synovitis and edema-like bone marrow lesions for initial diagnosis and as an indicator of disease progression can provide crucial information leading to therapeutic interventions before permanent joint damage occurs. Understanding the characteristic intra-articular and extra-articular MR imaging findings of the inflammatory arthritides allows the radiologist to provide appropriate consultations in the care of these patients. The MR appearances of both intra-articular and extra-articular findings of inflammatory arthritis are presented. Despite the advances in imaging, however, many of the MR findings remain nonspecific, and radiologists must avoid overdiagnosis by synthesizing all of the clinical information available into their interpretations.

[Radiographic healing of sarcoid bone erosion]

Sarcoidosis is a systemic granulomatous disease that primarily affects the lung and other organs. Patients with dactylitis should be screened for abnormalities of the skin, eyes and lungs. Even in patients with normal-range ACE sarcoidosis could be confirmed by tissue biopsy. Treatment with methotrexate and steroids can relieve symptoms and stabilize the disease. In refractory cases leflunomide, azathioprine, hydroxychloroquine or antibodies against TNF-alpha can be additionally administered.

Dactylitis, a term for different digit diseases

Dorland's Illustrated Medical Dictionary gives the following definition of dactylitis (deltaalphachitauupsilonlambdaomicronsigma = digit): 'inflammation of a finger or toe'. Although any inflammatory process involving the fingers or toes may be called dactylitis, the term has entered in current use only in some well-defined entities. These differ in the involved tissue of the digit and in the type of involvement. Tuberculous dactylitis is the variant of tuberculous osteomyelitis affecting the short tubular bone of the hands and feet. Radiographs typically show a central, lytic, cystic, and expansive lesion known as spina ventosa. Syphilitic dactylitis is a manifestation of congenital syphilis. Radiological findings mimic those of tuberculous dactylitis but the involvement is bilateral and symmetric. Sarcoid dactylitis is due to typical non-caseating granulomas invading the phalanges and the adjacent soft tissue. Blistering distal dactylitis is an infection of the anterior fat pad on the volar surface of the distal portion of a single finger or more rarely a toe, mostly caused by group A beta-haemolytic streptococci. Sickle cell dactylitis, also known as 'hand-foot syndrome', is due to localized bone marrow infarction of the carpal and tarsal bones and phalanges. Spondyloarthritis dactylitis, also called 'sausage-like' digit, is a diffuse painful swelling of the fingers and toes. Recent ultrasonography (US) and magnetic resonance imaging (MRI) studies on both finger and toe dactylitis have established that dactylitis is due to flexor tenosynovitis and that the enlargement of the joint capsule is not an indispensable condition for the 'sausage-like' feature. There is no evidence of enthesitis of flexor digitorum tendons and joint capsule.

Epithelioid hemangioendothelioma of the phalanx: a case report

Epithelioid hemangioendothelioma (EH) of a hand bone is extremely rare. We describe a patient with a phalangeal EH. This was treated by resection of the entire middle phalanx with no recurrence within a 10-year postsurgical follow-up period. We recommend wide resection as the safest treatment for EH of the hand phalanx.

Bone cysts in sarcoidosis: what is their clinical significance?

The incidence of bone cysts in sarcoidosis, a multisystemic disease, varies in different series, and these cysts are generally asymptomatic. We evaluated bone cysts in 516 sarcoidosis patients with available hand X-rays and in 200 patients with foot X-rays. Bone cysts were present in 21 cases (19 females, two males). The cysts were localized in phalanges of the hand in all cases, in feet in five cases, and in nasal bone in one. Six patients with bone cysts also had lupus pernio. Among those with cystic bone lesions, females were more frequent; extrapulmonary and skin involvement and lupus pernio were significantly more common. We diagnosed cystic bone lesions in 3.6% of our sarcoidosis patients and conclude that cysts were more frequent in females and in patients with lupus pernio.

The radiological appearance of recurrent phalangeal sarcoidosis

Sarcoidosis of the phalanx is rare and is usually associated with severe systemic disease. We present a patient with recurrent phalangeal sarcoidosis and new evidence of a changing radiological pattern. The clinical presentation and outcome is discussed. High dose steroid treatment and careful long-term follow-up is recommended.

Cutaneous sarcoidosis in black South Africans

BACKGROUND

It has been observed that, in the USA, sarcoidosis is more common in African-Americans than in other races. It has also been noted that sarcoidosis in African-Americans is characterized by more severe extrapulmonary involvement and more exuberant skin lesions. There is little information on sarcoidosis in black Africans.

METHODS

Fifty-four black South African patients with cutaneous lesions of sarcoidosis proven by biopsy were prospectively studied. Dermatologic and ophthalmologic examinations and chest X-rays were performed in all patients. Other investigations relevant in the diagnosis of extracutaneous sarcoidosis were also performed in a variable number of patients.

RESULTS

In 40 patients (71%), systemic sarcoidosis was found with lung, eye, and acral bone involvement being most common. Great variations in the morphology of skin lesions were observed. In one-quarter of patients, atypical cutaneous lesions (hypopigmented, ichthyosiform, lymphedematous, mutilating, ulcerative, verrucous) were found. Lupus pernio, once thought to be confined to Northern Europe, was observed in five patients in the subtropical milieu of South African Transvaal. Sarcoidal dactylitis with nail changes was seen in eight patients. Fibrinoid necrosis was found in 12% of the biopsies.

CONCLUSIONS

Sarcoidosis in black South Africans is characterized by extensive cutaneous involvement. The lesions are morphologically extremely variable, frequently atypical, and often demonstrate fibrinoid necrosis on histology.

Dactylitis: implications for clinical practice

OBJECTIVES

To assess the specificity of dactylitis for the diagnosis of spondyloarthropathy, sarcoidosis, and gout; and to characterize dactylitis specifically associated with gout.

METHODS

Dactylitis was prospectively assessed among all individuals presenting to the Arthritis Center of Northeast Ohio from 1986 to 1996.

RESULTS

Dactylitis was observed in 12% of individuals with spondyloarthropathy, 17% with sarcoidosis, and 5% with gout, but not in 96 patients with rheumatoid arthritis or in 2,434 patients with osteoarthritis, neck or back pain, or collagen vascular diseases. Among individuals with spondyloarthropathy, dactylitis was present in 22% with psoriatic, 28% with Reiter's syndrome, and only 7% with undifferentiated spondyloarthropathy. Gouty dactylitis was found only in individuals with polyarticular disease.

CONCLUSIONS

Dactylitis is a valuable clue in the differential diagnosis of arthritis. Compared with the wider spectrum in children, sausage-shaped digits have only a few known causes in adults: Reiter's syndrome, psoriatic arthritis, sarcoidosis, flexor tendon sheath infections, and gout. In our series, the presence of dactylitis eliminated rheumatoid arthritis from the differential diagnosis.

Subcutaneous sarcoidosis with dactylitis

Subcutaneous sarcoidosis appears to be rare and is usually associated with hiliar adenopathy. Finger swelling is well recognized in patients with sarcoidosis and usually results from bony involvement or tenosynovitis. We report a patient with subcutaneous sarcoidosis and dactylitis. Biopsy of a finger and of subcutaneous nodules showed similar features with a granulomatous infiltrate. There were no osseus or tendinous lesions.

A palmar plaque and flexor tenosynovitis in a patient with sarcoidosis

Involvement of the soft tissues of the hand by sarcoidosis is rare. We report a patient with sarcoidosis who presented with a large subcutaneous plaque of the palm and flexor tenosynovitis of the middle finger.

[Sarcoid synovitis. A case report of localization at the level of the flexor tendons of the fingers]

Sarcoidosis without bone involvement or sarcoid dactylitis, is a very unusual cause of flexor synovitis. Our reported patient initially presented with chronic arthralgia of the knees and ankles. The initial diagnosis of rheumatoid arthritis was incorrect. A surgical flexor synovectomy was performed to release painful compression of the median nerve due to the synovitis. The correct diagnosis was suggested by the histopathological examination showing noncaseating epithelioid granulomas. The diagnosis was confirmed by the association of a negative tuberculin test and raised angiotensin converting enzyme. No recurrence of synovitis occurred after surgical excision and colchicine therapy but arthralgia persisted.

Nail dystrophy in chronic sarcoidosis

We report details of five patients with nail dystrophy associated with sarcoidosis. All had bone cysts in the underlying terminal phalanx and had a chronic course of the disease. Radiological examination is indicated in patients with sarcoidosis and nail dystrophy as bone cysts are frequently asymptomatic.