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Lung Pathology |

Intractable Pruritus: Do We Think of Pulmonary Sarcoidosis?

Meera Yogarajah, MD; Bhradeev Sivasambu, MD; Olufemi Aina, MD
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Interfaith Medical Center, Brooklyn, NY


Chest. 2015;148(4_MeetingAbstracts):629A. doi:10.1378/chest.2260300
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Abstract

SESSION TITLE: Lung Pathology Student/Resident Case Report Posters

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Sarcoidosis is a granulomatous disorder characterized by the presence of non-caseating granulomas typically involving the lung. Approximately 25% of patients with sarcoidosis have cutaneous manifestations. However intractable pruritus in the absence of skin lesions is not a known skin manifestation of sarcoidosis.

CASE PRESENTATION: A 58 year old man presented with generalized intractable pruritus with no rash or wheals for few weeks. Patient denied any pulmonary symptoms. Review of other systems were negative. He had a history of diabetes mellitus, hypertension and Hepatitis C. Physical examination revealed genearlized excoriation. However there were no discernible skin lesions. Other system examination was unrevealing. His complete blood count was normal. He had renal impairment with blood urea nitrogen of 42 mg/dl and creatinine of 2.6 mg/dl. The corrected calcium was 12.8 mg/dl with elevated globulin. The working differential diagnoses were lymphoma, multiple myeloma, malignancy with bone metastasis or paraneoplastic hypercalcemia. As patient did not have any pulmonary manifestations or skin lesions sarcoidosis was not considered. Further workup was targeted in delineating the cause of hypercalcemia with pruritus. Parathyroid hormone was appropriately suppressed with a mildly elevated parathyroid hormone related peptide (PTHrP). 25-hydroxyvitamin D was low (10 ng/ml), with normal levels of 1,25-dihydroxyvitamin D. Serum electrophoresis revealed polyclonal gammopathy and urine electrophoresis was normal. Urine calcium excretion was elevated. Computed tomography of the chest, abdomen and pelvis for lymphoma workup incidentally showed reticulonodular opacities in the lungs and 8mm nodule in the left lower lobe. There were no lymph node enlargement in the thorax, abdomen and pelvis. Bone scan and skeletal survey were negative. Angiotensin converting enzyme level was elevated (193 U/l, normal range 12-68) raising the possibility of sarcoidosis. Bronchoscopic biopsy of the lung revealed noncaseating granuloma suggestive of sarcoidosis. A skin biopsy was not done as patient didn’t have any skin lesions. Patient was started on steroids and had improvement in his pruritus and his calcium levels normalized.

DISCUSSION: There are numerous skin manifestations of sarcoidosis. Skin lesions containing noncaseating granulomas are classified as specific lesions and all other skin findings are classified as nonspecific lesions. Isolated intractable pruritus is not a well-known skin manifestation of sarcoidosis. Literature review revealed only two cases of sarcoidosis which presented as pruritus.

CONCLUSIONS: This case shows that pulmonary sarcoidosis can rarely present with intractable pruritus without pulmonary symptoms. Knowledge on this rare skin manifestation will aid in early diagnosis and appropriate management of the disease.

Reference #1: Valdivielso Felices P, Pruritus and hypercalcemia as presentation of sarcoidosis. An Med Interna. 2002 Oct;19(10):546-7

DISCLOSURE: The following authors have nothing to disclose: Meera Yogarajah, Bhradeev Sivasambu, Olufemi Aina

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