Sarcoidosis. An updated review

Polymorphous Cutaneous Sarcoidosis With Excellent Response to Minocycline

Sarcoidosis is notorious for producing a wide variety of skin lesions, which are categorized as either specific or nonspecific. The specific lesions include primary morphologies ranging from micropapules to subcutaneous nodules. Nonspecific skin lesions include associated conditions like erythema nodosum, calcinosis cutis, and prurigo. It is not uncommon for a patient to have a combination of specific and nonspecific lesions. In contrast, it is exceedingly rare for one patient to have multiple specific sarcoidal lesions. When present, the term "polymorphous cutaneous sarcoidosis" has been used. We present the case of a patient who presented with three specific cutaneous morphologies of sarcoidosis: papular sarcoid, Darier-Roussy subcutaneous sarcoidosis, and lupus pernio. After only two months of oral minocycline, our patient demonstrated remarkable improvement with near-complete resolution of the cutaneous lesions. In addition to describing the rare polymorphous presentation, this case also highlights the challenge of relating lesion type to overall prognosis when multiple morphologies are present.

Sarcoidosis and Its Dermatological Manifestations: A Narrative Review

Sarcoidosis is an enigma diagnosed by ruling out other etiologies of granulomatous inflammation. The multisystem manifestations of sarcoidosis and the clinical polymorphism pose a diagnostic challenge to all physicians. The skin is the most commonly affected organ after the lungs in sarcoidosis. Dermatological manifestations can appear before, during, or after systemic involvement, and the type of skin lesion can have prognostic significance. Also, a biopsy of skin lesions is less invasive and more accessible to perform than a biopsy of visceral organs. Thus, in certain ways, cutaneous manifestations can aid in the diagnosis and prognosis of systemic disease. This article has focused on the frequently encountered skin lesions of sarcoidosis along with their prevalence, clinical features, and management.

Annular cutaneous sarcoidosis with systemic involvement

Sarcoidosis is a granulomatous disease involving multiple systems. Cutaneous involvement is present in 25% of patients. A 42-year-old woman presented with itchy skin lesions on her face for 5 years duration. She was found to have annular and discoid plaques with prominent overlying telangiectasia. A biopsy from the plaque was suggestive of sarcoidosis. On further evaluation, she was found to have both pulmonary and ocular involvements. Annular sarcoidosis is a rare variant of cutaneous sarcoidosis. We report this case to highlight this rare variant of sarcoidosis and discuss the various cutaneous manifestations of sarcoidosis.

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.

Hepatic sarcoidosis with an increased serum level of immunoglobulin G4

A 70-year-old woman with an increased uptake of 18-Fluorodeoxyglucose (FDG) in whole liver on positron emission tomography (PET) was referred to our hospital. Laboratory examinations showed increased serum levels of total immunoglobulin G (IgG) and IgG4. Gallium scintigraphy showed a remarkable uptake in the liver but not in any other organs. On computed tomography (CT) and magnetic resonance imaging (MRI), multiple foci of abnormal density were observed in the liver, but the pancreas and bile duct lacked any indications of IgG4-related sclerosing disease. A liver biopsy specimen revealed multiple non-necrotizing granulomas. This is the first report of hepatic sarocidosis in a patient with an elevated serum level of IgG4.

A case of morpheaform sarcoidosis

Sarcoidosis is an idiopathic multisystem disease with various cutaneous presentations, and it is characterized by the presence of non-caseating granulomas in the affected organs. The specific manifestations are papules, plaques, nodules, ulcers and scar. We report here on a variant of sarcoidosis on a 71-year-old woman who showed an indurated plaque on the forearm. Her lesion's appearance was clinically similar to that of a morphea and the appearance of the lesion was unlike the commonly observed manifestations of sarcoidosis.

Sarcoidosis Presenting as a Proximal Phalangeal Bony Swelling-a Case and Review of the Literature

We report a case of a 27-year-old man who presented with a progressive painful swelling at the base of his left index finger, with radiographs and a computed tomography scan revealing a lytic lesion of the proximal phalanx. Following further investigation, the patient underwent a bone biopsy that revealed a florid noncaseating granulomatous chronic inflammatory infiltrate, compatible with sarcoidosis. Osseous sarcoidosis of the hand is uncommon and, in the absence of significant systemic disease, is rarely the primary presenting feature. Early diagnosis and treatment of such undetermined bone pathology, via referral to a regional musculoskeletal tumor service, can prevent significant future complications.

A case of ichthyosiform sarcoidosis with unusual localization

Sarcoidosis is a systemic granulomatous disease of unknown cause that commonly involves the lungs, lymph nodes, bones, liver, spleen, or skin. Cutaneous findings of sarcoidosis occur in 20% to 35% of patients with systemic disease. The recognition of cutaneous lesions is important, because it gives important clues to diagnosis and also allows for easy biopsy. We report a 71-year-old Turkish woman with erythematous lesions, which included widespread, erythematous macules of various sizes on the chest, abdomen, and back on both sides of her body. Fine white scales covered some of the lesions. Hepatomegaly and bilateral hilar lymphadenopathy were also observed. Biopsy specimens of the skin showed dermal, noncaseating, epitheloid granulomas. The diagnosis, based on correlation of the clinical presentation and histopathological findings, was ichthyosiform sarcoidosis with systemic involvement. The difference between our case and other cases of ichthyosiform sarcoidosis described in the literature is that ours involved only the trunk and not the extremities. We are presenting this case because it is an interesting and rare variant of ichthyosiform sarcoidosis.

Giant verrucous nodules in a patient with tuberculosis

Sarcoidosis is a systemic inflammatory disorder characterized histologically by noncaseating granulomas in affected organs. Cutaneous manifestations of the disease such as papules, nodules, plaques, and ulcerations occur in approximately 25% of the patients. Sarcoidosis can present with multiple different morphologies including annular, psoriasiform, ichthyosiform, morpheaform, and verrucous. In this study, we report a 30-year-old African American man with a history of spinal tuberculosis as a child and slowly enlarging verrucous nodules that appeared at the age of 5 years. After an extensive infectious disease evaluation, the diagnosis of verrucous sarcoidosis was established with the presence of noncaseating granulomas and a completely negative workup for infectious etiologies.

A case of sarcoidosis occurring within an extensive burns scar

Scarring from burn injuries can result in cosmetic and functional deformities. In addition, late complications can also occur presenting as other pathology developing within the scarred tissue. We report a unique case of cutaneous sarcoidosis developing within a burns scar in an adult male who sustained a burns injury to his torso, right arm and thigh.

Cutaneous sarcoidosis: differential diagnosis

Sarcoidosis is a multisystem disease with cutaneous lesions present in 20%-35% of patients. Given the wide variability of clinical manifestations, it is one of the "great imitators," making it necessary to consider clinical, epidemiological, radiographic, laboratory, and histopathological criteria to make the diagnosis. Cutaneous lesions have been classified as specific and nonspecific, depending on the presence of noncaseating granulomas on histologic studies. Specific lesions include maculopapules, plaques, nodules, lupus pernio, scar infiltration, alopecia, ulcerative lesions, and hypopigmentation among others. Nail, mucosal, and childhood sarcoidosis represent a distinct subset of the disease process. The most common nonspecific lesion is erythema nodosum. Others include calcifications, prurigo, erythema multiforme, nail clubbing, and Sweet syndrome. The importance of considering cutaneous sarcoidosis in the clinical differential diagnosis of a given skin lesion relies on the association with systemic involvement and the convenience of the skin as a tissue source for histologic analysis.

Cutaneous manifestations of lung disease

Skin disease may be associated with pulmonary disease in a variety of ways. This article describes cutaneous manifestations of selected pulmonary conditions and other associations between the skin and lung.

A retrospective study of cutaneous equine sarcoidosis and its potential infectious aetiological agents

Nine horses from ages 5 to 21 years were diagnosed with cutaneous equine sarcoidosis (ES) over an 18-year period. In addition to skin, the lungs were frequently involved, with other organ systems affected less commonly. A predisposition for thoroughbreds and geldings was noted. Cutaneous lesions and signs included crusts, scales, alopecia and pruritus. These were found at various sites, particularly the legs/thighs/elbows, thorax, neck, face and ventral abdomen. Three horses were euthanized shortly after hospitalization; others survived as long as 12 years. Histopathologic stains, immunohistochemistry and polymerase chain reaction assays on paraffin-embedded cutaneous specimens from eight horses for Mycobacterium spp., Coccidioides immitis, Cryptococcus neoformans, Corynebacterium pseudotuberculosis, and Borrelia burgdorferi were all negative. The aetiology of ES is unlikely microbial and continues to be a diagnosis of exclusion. ES, when limited to the skin, is associated with a good prognosis, with either partial or complete response to glucocorticoid therapy in all the surviving horses.

Osseous sarcoidosis of the hand: pathologic analysis and review of the literature

A destructive granulomatous process involving the right fifth metacarpal and the soft tissues of the right thumb and nose of an African-American woman without pulmonary disease is described. The initial biopsy examination of the metacarpal showed caseating and noncaseating granulomata. After a fifth-ray amputation the disease progressed, leading to the referral of the patient to our institution. A biopsy examination of this recurrence showed a predominance of solid noncaseating granulomata. The diagnosis of sarcoidosis was made on the basis of the morphology of the granulomata and by exclusion of infectious and neoplastic causes. Steroid therapy has resulted in cessation of clinical and radiographic disease progression at a 3-year clinical follow-up evaluation.

Scleritis associated with sarcoidosis

PURPOSE

To review scleritis cases associated with sarcoidosis and to evaluate clinical features, medical treatment, and clinical course.

METHODS

Two cases of diffuse anterior scleritis and a nodular scleritis case associated with systemic sarcoidosis were evaluated. Scleritis was the first manifestation of sarcoidosis in two of the patients and the diagnosis of sarcoidosis was confirmed with a conjunctival biopsy. The third patient had the diagnosis of systemic sarcoidosis when she developed scleritis.

RESULTS

Based on the clinical and histological appearance, two patients presented with bilateral diffuse anterior scleritis and the third patient with an anterior nodular scleritis. One patient already had the diagnosis of systemic sarcoidosis at presentation, while ocular findings led to the diagnosis in the other two cases. Conjunctiva or skin biopsies revealed features compatible with the diagnosis of sarcoidosis. Scleritis attacks recurred in two patients. All patients responded well to systemic corticosteroid (prednisone) therapy.

CONCLUSIONS

Scleritis associated with sarcoidosis has rarely been described and it may be the presenting sign of systemic sarcoidosis.

Diabetes insipidus from neurosarcoidosis: long-term follow-up for more than eight years

Four patients with sarcoidosis presented as hypothalamic-hypophyseal syndrome including diabetes insipidus (DI) were followed up for more than 8 years from the onset of clinical manifestation. The mean age was 26 years, male : female ratio was 3 : 1 and the mean disease duration of 10 years. All patients had hypogonadism, hyperprolactinemia. Pituitary enlargement with thickening of the pituitary stalk were detected by magnetic resonance imaging (MRI) with gadolinium enhancement and attenuation in the intensity of the posterior lobe of the pituitary was detected without enhancement. Corticosteroid therapy resulted in the initial improvement of symptoms and gradual decrease in the tumor size but failed to cure polyuria due to DI. The use of desmopressin was necessary for a long period. None of these patients died from DI or central neurosarcoidosis.

Clinicopathologic features of ulcerative-atrophic sarcoidosis

BACKGROUND

Sarcoidosis is a chronic granulomatous disease of unknown etiology. Cutaneous disease is common and includes two clinicopathologic categories: granulomatous infiltration or a reactive phenomenon. In the granulomatous infiltrative group, clinical manifestations can be variable. Ulcers in sarcoidosis are uncommonly recognized and have been categorized previously under the rubric of atrophic, necrobiosis-like, or ulcerative sarcoidosis.

PATIENTS AND METHODS

We evaluated retrospectively sarcoidosis patients presenting to the Johns Hopkins Department of Dermatology between June 1989 and May 2002. Multiple skin biopsies were performed for histopathologic evaluation. Investigation for extracutaneous manifestations, including routine serologic assays, chest radiography, pulmonary function tests, electrocardiogram, and angiotensin-converting enzyme level, and referral for ophthalmologic examination were performed in all patients.

RESULTS

Of 147 consecutive patients presenting with cutaneous sarcoidosis, seven demonstrated ulcerative-atrophic sarcoidosis lesions. All patients were African-American (five females and two males). All patients had ulcers surrounded by atrophic necrobiosis lipoidica-like plaques on the pretibial areas. All patients had other mucocutaneous manifestations of sarcoidosis, with the majority having evidence of internal disease. Combined immunosuppressive and immunomodulatory therapy was effective in controlling the cutaneous manifestations of all patients with ulcerative sarcoidosis.

CONCLUSIONS

The ulcerative variant is a poorly defined subset of cutaneous sarcoidosis. Trauma, superimposed on atrophic plaques, appears to be the principal mechanism of this rare variant of cutaneous sarcoidosis.

Treatment of cutaneous sarcoidosis with thalidomide

BACKGROUND

Although systemic corticosteroids are effective against cutaneous sarcoidosis, alternative therapies are needed.

OBJECTIVE

We sought to assess the efficacy and tolerance of thalidomide for cutaneous sarcoidosis.

METHODS

We performed a retrospective evaluation of thalidomide (100-200 mg/d) in 12 consecutive patients with cutaneous sarcoidosis treated in a university hospital between 2000 and 2002.

RESULTS

Cutaneous lesions regressed within 1 to 5 months, with an average time of 2 to 3 months for 10 patients. In all, 4 patients achieved complete responses, 6 had partial responses, and 2 had no regression. Nasopharyngeal, pulmonary neurologic, and hepatic symptoms were also attenuated. Thalidomide was well tolerated. The main adverse effect was deep vein thrombosis in 1 patient.

CONCLUSION

Thalidomide efficacy and tolerance in patients with cutaneous sarcoidosis merits further evaluation in a controlled trial.

Idiopathic granulomatous pneumonia in seven horses

The history, clinical signs and pathological findings in seven adult horses with histologically confirmed idiopathic granulomatous disease, primarily of the lungs, are reviewed. They ranged in age from eight to 21 years, five were geldings and two were females, they belonged to five breeds and there were no seasonal or geographical associations. The primary clinical signs were chronic weight loss, exercise intolerance and respiratory distress which did not respond to conventional treatment. The most consistent physical findings were depression, anorexia, tachycardia, tachypnoea and adventitious lung sounds. Thoracic radiographs revealed a diffuse, structured, nodular, interstitial pulmonary pattern in each horse. Haematological measurements suggested a chronic inflammatory process and the cytology of transtracheal washes was consistent with a mild suppurative inflammation. Idiopathic granulomatous pneumonia was confirmed histologically in each of the horses, either postmortem or by a lung biopsy. The horses responded poorly to medical treatment and only one of three treated horses is still alive.

Hair and scalp disorders in ethnic populations

Treating scalp and hair disorders is challenging because of the emotional nature of hair loss and because of unknown pathogenesis. Treating African American patients can add an extra layer of complexity to this treatment if the dermatologist is not familiar with hair care practices. Only the dermatologist who strives to understand hair care practices, the common disease entities of the hair and scalp in African Americans, and the disturbance in quality of life from alopecia will effectively approach treatment in these patients.

Sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown cause that most commonly affects the lungs, lymph nodes, skin, eyes, spleen, bone, and glandular tissue. The diagnosis is made when characteristic histologic findings are demonstrated and other granulomatous processes are excluded. It can be an acute or chronic debilitating disease, but in patients with acute disease the process can be self-limited. Multiple therapeutic options have been described both for the cutaneous and systemic lesions of sarcoidosis. Steroids, however, remain the cornerstone of therapy.

Cheilitis granulomatosa

Cheilitis granulomatosa is a rare inflammatory disorder with unclear aetiology. It is a disorder characterized by recurrent or persistent swelling of one or both lips that may be part of the Melkersson-Rosenthal syndrome or may be a manifestation of Crohn's disease. An overview of the clinical features, histopathology, differential diagnosis, management strategies and prognosis of cheilitis granulomatosa is presented and discussed with regard to the literature.

Diagnosis and management of neurosarcoidosis

Sarcoidosis is a multisystemic disorder characterised by the presence of multiple noncaseating granulomas. Clinically recognisable nervous system involvement occurs in 5-16% of patients with sarcoidosis. However, the incidence of subclinical neurosarcoidosis may be higher. The following article presents a review of the disease, including its pathophysiology, clinical and radiological characteristics and treatment. Neurosarcoidosis should be included in the differential diagnosis of infectious and noninfectious neurological syndromes.

Sarcoidosis

Sarcoidosis is a systemic noncaseating granulomatous disorder of unknown origin. The cutaneous manifestations of sarcoidosis often enable the dermatologist to be the first physician to make the diagnosis. This article reviews essential sarcoidosis pathophysiology, clinical polymorphisms, systemic evaluation, and treatment modalities for cutaneous sarcoidosis to further enhance the dermatologist's understanding of this disease entity.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the theories of the pathogenesis of sarcoidosis, its cutaneous manifestations, its various syndromes and associations, and its presentation in children. Participants should also be more knowledgeable about diagnostic evaluation, measurement of disease progression, treatment modalities, and the prognosis and mortality data of sarcoidosis.

Multiple indurated papules on penis and scrotum

BACKGROUND

Sarcoidosis is a chronic disease with involvement of multiple organs. Cutaneous lesions may appear as the only manifestation or may be accompanied by systemic disease.

OBJECTIVE

To learn that genital sarcoidosis is a rare entity that should be included in the differential diagnosis of genital papules and nodules.

METHODS AND RESULTS

A 31-year-old African-American man presented with cutaneous lesions on his penis and scrotum existing for 2 years. The genital lesions were so prominent as to interfere with his sexual life. Sarcoidosis was demonstrated on biopsy.

CONCLUSIONS

Sarcoid lesions may affect any skin area, but are rarely described on the genitalia. Dermatologists should be aware that genital sarcoidosis is a rare entity that should be included in the differential diagnosis of genital papules and nodules. Additionally, genital sarcoidosis may cause urinary problems and may represent a therapeutic challenge.

Extrapulmonary sarcoidosis primarily diagnosed in the liver

Sarcoidosis is a relatively common, chronic, multisystem disease of unknown origin characterized by the presence of noncaseating epithelioid granulomas. Although an array of organs may be affected by the disease, the commonest site of affection is the lung. We describe a 73-year-old patient admitted to our hospital because of fatigue, weight loss, and an increased alkaline phosphatase level. In conjunction with clinical presentation, laboratory variables, and imaging analysis, a liver biopsy finally confirmed the diagnosis of a systemic sarcoidosis without affection of the lung or mediastinal lymph nodes. Treatment with ursodeoxycholic acid before diagnosis did not improve clinical symptoms and cholestasis indicators. After prednisone treatment, liver enzyme values normalized and remained normal during follow-up for 2 years after diagnosis. The literature on hepatic manifestation of sarcoidosis, its diagnosis, treatment, and prognosis is reviewed. This single case of sarcoidosis presented to the clinician almost exclusively with liver enzyme abnormalities. The consideration of sarcoidosis in such cases is of utmost importance, since the differential diagnosis of hepatic granulomas includes infectious diseases in which treatment with corticosteroids could be fatal.