Cutaneous sarcoidosis with tuberculoid granuloma

Smitha Warrier, AS Muhammed Fassaludeen, B Safia

 Department of Dermatology and Venereology , Medical College, Calicut-673 008, India

Correspondence Address:
B Safia
30/241 Kavoor, Medical College PO, Calicut-673 008
India

Introduction

Sarcoidosis is an idiopathic multisystem granulomatous disease that commonly involves the lungs, eyes, lymphnodes and skin. Cutaneous involvement occurs in 20% to 30% of patients with systemic disease.[1] Cutaneous involvement can precede, occur concurrently with or occur after onset of systemic disease.

Case Report

A 65- year-old man presented with a reddish lesion on his back of 3 years duration. It had been increasing in size lately and new lesions were appearing on his arms. Examination showed a large 10 x 10cm erythematous plaque with well defined borders and minimal scaling on his back. [Figure - 1], [Figure - 2] There were similar smaller lesions on his arms. Sensations over the lesions were normal. His finger nails showed brownish black longitudinal ridging and his toe nails showed blackish discolouration. Systemic examination was within normal limits. Routine blood and urinalysis, renal function tests, liver function tests and random blood sugar were normal. Serum calcium and angiotensin converting enzyme levels were normal. Chest X-ray showed bilateral hilar lymphadenopathy. CT scan confirmed this. Sputum AFB and Mantoux test were negative. Skin biopsy showed tuberculoid granulomas without caseation in the dermis. Wade Fite and Gomorri′s methanamine silver staining were negative. Since the patient did not have any chest symptoms, he was initially treated with potent topical steroids only. The lesions responded to treatment initially with decrease in thickness of the plaque. But after 2 months there was a slight increase in the thickness of the plaque. He was then put on systemic steroids and is responding very well.

Discussion

Besnier reported the first case of sarcoidosis in 1889. First case in India was reported by Rajam et al in 1957. Sarcoidosis of the skin occurs in approximately 20-30% of patients with systemic sarcoidosis.[2] Cutaneous sarcoidosis can also occur without systemic disease. 2 types of cutaneous lesions are recognized- specific and non specific. The specific lesions are those which show the typical granuloma-the characteristic feature is the presence of circumscribed epitheloid granulomas with little or no caseation, a few multinucleate giant cells and only sparse infiltrates of lymphocytes at the periphery of the granuloma; unusually dense lymphocytic infiltrate is seen surrounding the epitheloid histiocytes as in a tuberculoid granuloma.[3] The nonspecific lesions do not show the typical granuloma. Nail involvement is rare.[4] Nail changes reported include thickening, opacity, fragility, layering, convexity, longitudinal ridging, pitting, atrophy, nail loss, pterygium and red or brown discolouration of the nail beds.

1.	Samtson AV. Cutaneous sarcoidosis. Int J Dermatol 1992; 31: 385-391. [Google Scholar]
2.	Gharpode A, Ramanan C. Cutaneous sarcoidosis. Indian J Dermatol Venereol Leprol 1996;62:171-172. [Google Scholar]
3.	Philip E. Shapiro. Levers Histopathology of the skin. Page 324-325. [Google Scholar]
4.	Patel KB, Sharma OP Nails in sarcoidosis: response to treatment. Arch Dermatol 1983;119: 277-278. [Google Scholar]