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Signs and Symptoms of Chest Diseases |

Subcutaneous Nodules: A Rare Presentation of Systemic Sarcoidosis

Juan Rojas Balcazar*, MD; Vikas Pathak, MD; Peadar Noone, MD
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University of North Carolina at Chapel Hill, Chapel Hill, NC


Chest. 2012;142(4_MeetingAbstracts):976A. doi:10.1378/chest.1387934
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Abstract

SESSION TYPE: Miscellaneous Case Report Posters I

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: Sarcoidosis is a multi-system disease of undetermined etiology, characterized by the presence of non-caseating granulomas. The lung is affected in about 90% of the patients, but other organs can be involved including heart, skin, CNS, kidney, liver, eye and skin. Cutaneous sarcoidosis has been reported in 25% of the cases and subcutaneous involvement is the less frequent of the cutaneous lesions of sarcoidosis. We describe a case of a patient presenting with subcutaneous nodules in absence of systemic symptoms.

CASE PRESENTATION: A 52-year-old man presented with a right hand and forearm subcutaneous swelling present for ~3 months. He was healthy other than having had a recent deep vein thrombosis secondary to an ankle fracture treated with warfarin. The subcutaneous swelling was initially soft and then became firmer with no associated pain, erythema, discoloration or discharge. There was no apparent history of trauma to the area, nor were there respiratory symptoms, such as cough, shortness of breath, chest pain, fever, chills, night sweats or joint pains. The patient works as a sales executive, and is a lifelong non-smoker with no significant occupational exposure. Of note, there is a family history of sarcoidosis (in a maternal aunt). On physical examination, there was no lymphadenopathy. Cardiovascular and pulmonary systems were normal. The right forearm and hand revealed non-tender, firm and freely movable subcutaneous nodules with no erythema. A magnetic resonance imaging study of the area showed a non-specific mass within the subcutaneous fat, with no evidence of muscular invasion or osseous involvement. An excisional biopsy of the subcutaneous mass was done, which revealed numerous non-caseating granulomas, with chronic inflammation. Bacterial, mycobacterial and fungal cultures were negative. A subsequent CT of the chest showed multiple sub-centimeter mediastinal lymph nodes, without parenchymal involvement. Pulmonary function tests showed mild obstructive impairment, with a significant post-bronchodilator response, with normal volumes and gas exchange. Prednisone 40 mg/day was started with decreased swelling.

DISCUSSION: Subcutaneous sarcoidosis is a rare presentation of systemic sarcoidosis. Evidence of systemic involvement can be seen in 77% of the cases, mostly with mediastinal lymphadenopathy, however the diagnosis can be challenging in patients with no systemic symptoms.

CONCLUSIONS: Tissue biopsy is the gold standard for the diagnosis of subcutaneous sarcoidosis. Subcutaneous sarcoidosis can be effectively treated with prednisone for 4 to 8 weeks. Subcutaneous nodules in otherwise asymptomatic patients warrant further investigation to rule out systemic sarcoidosis with subcutaneous involvement.

1) Dalle Vedove C, Colato C, Girolomoni G. Subcutaneous sarcoidosis: report of two cases and review of the literature. Clin Rheumatol. 2011 Aug;30(8):1123-8.

DISCLOSURE: The following authors have nothing to disclose: Juan Rojas Balcazar, Vikas Pathak, Peadar Noone

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University of North Carolina at Chapel Hill, Chapel Hill, NC

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