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E-IJD CORRESPONDENCE
Year : 2015  |  Volume : 60  |  Issue : 1  |  Page : 107
Subcutaneous sarcoidosis with underlying intramuscular granuloma


Department of Dermatology, Fukushima Medical University, Fukushima, Japan

Date of Web Publication26-Dec-2014

Correspondence Address:
Toshiyuki Yamamoto
Department of Dermatology, Fukushima Medical University, Fukushima
Japan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.147887

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How to cite this article:
Ohashi T, Yamamoto T. Subcutaneous sarcoidosis with underlying intramuscular granuloma . Indian J Dermatol 2015;60:107

How to cite this URL:
Ohashi T, Yamamoto T. Subcutaneous sarcoidosis with underlying intramuscular granuloma . Indian J Dermatol [serial online] 2015 [cited 2020 Feb 24];60:107. Available from: http://www.e-ijd.org/text.asp?2015/60/1/107/147887


Sir,

Sarcoidosis is a systemic granulomatous disorder of unknown etiology. Approximately, 25% of patients have cutaneous lesions, which exhibit different manifestations depending on different races. [1] Specific manifestations include plaques, papules, maculopapules, subcutaneous nodules, infiltrative scars, and lupus pernio. Subcutaneous sarcoidosis usually occurs on the upper extremities, but lower extremities and buttocks are also involved. Histological examination shows non-caseating epithelioid granuloma located in the subcutis. We report herein a rare case presenting with subcutaneous sarcoidosis on the lower legs, in which biopsy specimen contained underlying intramuscular sarcoidal granuloma.

A 57-year-old female was diagnosed with sarcoidosis, initially presented with subcutaneous nodule on the buttock. A biopsy was taken at the department of orthopedic surgery, which revealed subcutaneous epithelial cell granuloma without caseation necrosis. Laboratory examination showed increased serum levels of angiotensin-converting enzyme (ACE) (48.2 IU/L; normal, 7-25) and positive antinuclear antibody (1:160, homogenous), whereas specific antibodies (SS-A, SS-B, Sm, Scl-70) were all negative. Blood chemistry data including liver, renal and creatine phosphokinase were within normal ranges. Lung computed tomography (CT) indicated multiple small nodules and hilar lymphadenopathy. Ophthalmologic and cardiac examinations were normal. On physical examination at the initial visit to our department, she had scar sarcoid on the knees, papular lesions on the elbow. Also, she developed subcutaneous tenderness on the lower legs [Figure 1]. A biopsy specimen showed sarcoidal granuloma in the subcutaneous tissues [[Figure 2]a and b]. Furthermore, granulomatous lesions with multinuclear giant cells were detected in the muscle in the same specimen [Figure 2]c. She did not have any symptoms of myopathy.
Figure 1: Subcutaneous induration on the anterior lower leg

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Figure 2: (a) Low magnification of histological features showing granulomatous lesions in the subcutis as well as muscle (H-E stain, ×20). (b) Higher magnification reveals circumscribed non-caseating epithelioid granulomas in the subcutaneous tissues (H-E stain, ×200). (c) Intramuscular granuloma with multinuclear giant cells in the same specimen (H-E stain, ×200)

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Subcutaneous nodules belong to one of the minor clinical forms of sarcoidosis, which presents with asymptomatic or slightly tender lesions frequently involving the upper extremities, with a slight predominance of females than males. [2] The nodules vary from 0.5 cm, firm, mobile nodules to large sclerotic plaques. In the presented case, we carried out biopsy from the subcutaneous induration of the lower leg. The surface was normal skin color and small subcutaneous nodules were palpable. Histological features revealed sarcoidal granuloma in the subcutaneous tissues, as well as granuloma in the muscle below the adipose tissues in the same specimen. Subcutaneous sarcoidosis is closely associated with systemic manifestations, such as lung involvement, uveitis, lymphadenopathy, arthritis, mucositis, dactylitis, neurological and renal involvement, and hepatosplenomegaly. [3] By contrast, muscle involvement has not been referred.

Symptomatic sarcoid myopathy is seen in only 0.5-5% of patients with sarcoidosis, whereas asymptomatic involvement can be detected in 25-75%. [4] Symptomatic myopathy are classified into three forms: Chronic myopathy, palpable nodules, and acute myositis. Nodular form is quite rare, and patients present with painful nodules on the muscle of the extremities. To make a diagnosis of sarcoidosis, it is necessary to confirm sarcoid granuloma from different organs. In the present case, myopathy was not accompanied, and detection of muscle granuloma may be coincidental. To date, only limited cases of sarcoidosis with musculocutaneous involvement have been reported. [5] However, it might be better to carry out skin biopsy including the underlying muscle, when sarcoidosis is suspected.

 
   References Top

1.
Heath CR, David J, Taylor SC. Sarcoidosis: Are there differences in your skin of color patients? J Am Acad Dermatol 2012; 66:121.e1-14.  Back to cited text no. 1
    
2.
Ahmed I, Harshad SR. Subcutaneous sarcoidosis: Is it a specific subset of cutaneous sarcoidosis frequently associated with systemic disease? J Am Acad Dermatol 2006;54:55-60.  Back to cited text no. 2
    
3.
Dalle Vedove C, Colato C, Girolomoni G. Subcutaneous sarcoidosis: Report of two cases and review of the literature. Clin Rheumatol 2011;30:1123-8.  Back to cited text no. 3
    
4.
Barnard J, Newman LS. Sarcoidosis: Immunology, rheumatic involvement, and therapeutics. Curr Opin Rheumatol 2001;13:84-91.  Back to cited text no. 4
    
5.
Singh AK, Dworkin HJ, Dickinson CZ, Sagar P. Sarcoidosis with musculocutaneous involvement. Clin Nucl Med 2001;26:951-2.  Back to cited text no. 5
    


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