Cases reported "Sarcoidosis"

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1/38. sarcoidosis presenting as nail dystrophy.

    A 45-year-old woman was referred to the dermatology clinic for assessment of "refractory onychogryphosis." She had a 3-year history of lesions involving distal phalanges of the first and third of her left foot. Initially she described periungual erythema and swelling. Three weeks later she noted a whitish growth and thickening of her third toenail. X-ray films of the digit were reported as normal. Several months later the same changes occurred in her great toe. These lesions were asymptomatic. There was no history of trauma. Numerous fungal cultures were negative. No light microscopic examinations were undertaken. She had a trial of both topical and systemic terbinafine of 3-months duration with no clinical improvement. Several clinical opinions were obtained from two dermatologists, a surgeon, and a chiropodist. Past medical history of note was significant for tubal ligation, cervical cancer, and chronic sinusitis. The latter condition in retrospect was thought to be secondary to sarcoidosis. physical examination revealed periungual violaceous discolouration of the first and third toes of the left foot. There was evidence of significant nail changes including dystrophy, onycholysis, and hyperkeratosis (Fig. 1). The fingernails were normal. There were no other skin abnormalities. A punch biopsy of the tip of the third toe showed granulomatous inflammation. There was evidence of hyperkeratosis, exocytosis, and a dense infiltrate composed of collections of histiocytes and a few giant cells forming granulomas (Fig. 2). Repeat x-ray films of the foot showed soft tissue swelling of the first and third digits. There was bony resorption in the distal phalanges with a lacey trabecular pattern compatible with sarcoidosis (Fig. 3). Chest x-ray films revealed marked hilar adenopathy. The patient was sent to a respirologist who concurred with the diagnosis of sarcoidosis. Further investigations included a low serum calcium of 2.07 mmol/L, serum ACE of 70 U/L (upper limit of normal is 75), Wintrobe erythrocyte sedimentation rate (ESR) of 10 mm per hour, thyroid stimulating hormone concentration of 0.65 mU/L, and a urinary calcium excretion rate that was elevated at 7.3 mmol/day. Pulmonary function tests were unremarkable. The patient was initially treated with clobetasol under occlusion and intralesional triamcinolone with minimal improvement. She was subsequently started on prednisone, 15 mg per os daily because of the lung and bone involvement with significant improvement noted in the toe lesions with diminution of both the swelling and violaceous discolouration.
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2/38. A 65-year-old factory worker with dyspnea on exertion and a normal chest x-ray.

    Chronic beryllium disease is an occupationally acquired granulomatous lung disease similar to sarcoidosis. It is caused by exposure to beryllium in genetically susceptible persons. It should be suspected in patients with beryllium exposure who present with pulmonary symptoms or have a positive screening blood beryllium-specific lymphocyte proliferation test. The diagnosis is confirmed by the finding of granulomas on transbronchial biopsy in the appropriate clinical and epidemiologic setting. Although there is no cure, treatment with corticosteroids is usually beneficial. In view of the potential side effects, treatment is reserved for patients with symptoms or a decline in pulmonary function.
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3/38. sarcoidosis with giant parotomegaly.

    We report the case of a 63-year-old man with bilateral parotid gland sarcoidosis. Giant, elastic, hard, subcutaneous tumors had been present on the right parotic and submaxillary regions for 11 years and on the left for 1 year. The patient had had diabetes mellitus for 8 years. Noncaseating epithelioid cell granulomata were revealed histopathologically in the periductal area of the parotid gland. Bilateral hilar lymphadenopathy was noted on chest x-ray studies. serum levels of lysozyme were increased. Levels of serum angiotensin-converting enzyme were within normal limits. tuberculin skin reaction was positive. The tumors gradually improved after treatment with oral minocycline. Giant parotomegaly, as it occurred in this case, is very rare.
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4/38. Extrathoracic sarcoidosis in a Chinese man presenting with multiple, large plaques and tumors.

    We report an unusual case of tumorous sarcoidosis in a 42-year-old Chinese man with extrathoracic sarcoidosis. He presented with multiple large plaques and tumors on the neck and extremities of a nine-year duration. Because of the atypicality of the cutaneous manifestation, the lack of intrathoracic lesions and the rarity of sarcoidosis in taiwan, the case remained undiagnosed for nine years despite numerous examinations and tests. A subsequent skin biopsy revealed sarcoidal granulomas. The detection of cytoplasmic birefringent inclusions in the granulomas led to the final diagnosis. Originally thought to be foreign bodies, the inclusions were proven to be calcium oxalate by x-ray microanalysis and calcium oxalate stain. Lymph node and liver biopsies confirmed the diagnosis. The skin lesions in this case may have been precipitated by frequent harsh scrubbing to clean the skin. sarcoidosis should be considered in the differential diagnosis in patients presenting with multiple cutaneous tumors. This case also illustrates that detection of calcium oxalate inclusions in granulomas, while not specific, can serve as a valuable clue in the diagnosis of cutaneous sarcoidosis.
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5/38. Fine needle aspiration biopsy cytology as an adjunct in the diagnosis of childhood sarcoidosis.

    Fine needle aspiration biopsy cytology performed in three children with sarcoidosis expedited clinical investigation and diagnosis of their disease. Each patient had a different clinical presentation; in two of them lymphoma was part of the initial differential diagnosis. Aspiration cytology in all cases revealed collections of epithelioid histiocytes, and multinucleate foreign body-type giant cells, without accompanying necrosis or acute inflammation. A diagnosis of non-caseating granulomas consistent with sarcoidosis was made in all aspirates. Special stains for identification of organisms performed on the smears of one case, and culture of aspirate material from one case were negative. Subsequent serum angiotensin converting enzyme levels in all patients were elevated. Chest x-ray films in all patients showed mediastinal and hilar lymphadenopathy. One patient had an interstitial pulmonary infiltrate. All patients responded to steroid therapy. Fine needle aspiration biopsy can be a useful diagnostic tool in the evaluation of children with suspected sarcoidosis.
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6/38. Symptomatic osseous sarcoidosis with findings on bone scan.

    Twenty-one years after the onset of sarcoidosis, a 51-year-old woman experienced pain in the lower portion of her back, which proved to be the result of sarcoidosis involving the pelvis. The pelvic abnormality consisted of osteosclerotic and osteoblastic lesions. A bone scan showed several other areas of increased uptake, and the diagnosis was confirmed by bone biopsy. The patient improved with treatment with steroids, but the findings on the x-ray film and the bone scan did not change. sarcoidosis may cause obscure, but symptomatic, osseous lesions.
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7/38. sarcoidosis presenting as colonic polyposis: report of a case.

    A 47-year-old, West Indian male was referred for investigation of mild iron-deficiency anemia. He was asymptomatic. Two years earlier, he had an episode of transient facial weakness and a separate episode of diplopia. gastroscopy and duodenal biopsies were normal. barium enema demonstrated multiple small polyps throughout the colon. At colonoscopy, these polyps had the appearance of adenomatous polyps. histology revealed noncaseous epithelioid granulomas. There were no acid-fast bacilli, no intervening colitis, and no features of Crohn's disease on small-bowel radiology. Chest x-ray demonstrated bilateral hilar lymphadenopathy. A diagnosis of sarcoidosis with colonic involvement has been made. Sarcoid has been described at various sites in the gastrointestinal tract, presenting with stricturing or ulceration. There have been no previous reports of sarcoidosis presenting as discreet colonic polyps.
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8/38. Development of sarcoidosis in cosmetic tattoos.

    BACKGROUND: The development of granulomatous lesions within tattoos is a well-recognized occurrence in individuals with sarcoidosis. The characteristic histopathological finding of sarcoidosis is the presence of noncaseating granulomas; however, similar histopathogical findings may be seen in foreign body granulomas. Several reports have challenged the assertion that the presence of foreign material within sarcoidal granulomas is incompatible with a diagnosis of sarcoidosis. OBSERVATIONS: We describe a patient who had multiple linearly arranged papules along her eyebrows and the vermillion border of her upper lip. She had had cosmetic tattooing performed on these areas 3 year prior to presentation. Histopathologic examination revealed sarcoidal granulomas, polarizable foreign material, and pigment granules. Hilar adenopathy was noted on a chest radiograph. After 4 months of treatment with a midpotency topical steroid and doxycycline, she experienced complete clearance of her cutaneous lesions and normalization of chest x-ray film findings. CONCLUSIONS: This case demonstrates a unique adverse result after cosmetic tattooing and highlights the concept that granulomatous histopathologic findings containing foreign material should not be an exclusionary criterion for the diagnosis of sarcoidosis. In this setting, further investigation for the presence of systemic disease is indicated.
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9/38. Multiple venous thromboses in a young man with sarcoidosis: is there a relation between sarcoidosis and venous thrombosis?

    We describe the case of a 33-year-old African-American male who presented with multiple deep venous thromboses of the upper and lower extremities. Hypercoagulable workup was unrevealing. A chest x-ray showed bilateral hilar lymph node enlargement. mediastinoscopy with hilar lymph node biopsy was performed. Lymph node histopathologic examination showed noncaseating granulomas. Lymph node tissue culture and special stains were negative for mycobacterial or fungal infection. This is an unusual case of multiple deep venous thromboses and sarcoidosis. The subject of sarcoidosis and venous thrombosis is discussed.
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10/38. sarcoidosis presenting as recurrent alcohol-induced pancreatitis.

    A previously well 27-year-old Caucasian woman presented with five episodes of alcohol-induced abdominal pain over two years culminating in severe acute pancreatitis. Chest x-ray showed bilateral hilar lymphadenopathy and nodular pulmonary infiltrates. In hospital she developed a unilateral facial nerve palsy and other features of sarcoidosis, which was confirmed by biopsy of a pretracheal lymph node. No previous case is reported of sarcoidosis presenting with recurrent pancreatitis apparently induced on each occasion by moderate alcohol consumption and in the absence of other risk factors. Pancreatic involvement as part of sarcoidosis is uncommon but is treatable if recognized and has a good prognosis.
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