Sarcoidosis is a systemic disease of unknown etiology with multi-system affection. It typically involves the skin, eyes, hilar lymph nodes, and pulmonary parenchyma. However, as any organ system could be involved, one has to be aware of its atypical manifestations. We present three uncommon manifestations of the disease. Our first case presented with fever, arthralgias, and right hilar lymphadenopathy with a history of tuberculosis in the past. He was treated for tuberculosis but had a relapse of symptoms three months after completion of treatment. The second patient presented with a headache for two months. On evaluation, cerebrospinal fluid examination showed evidence of aseptic meningitis, while an MRI of the brain demonstrated enhancement of the basal meninges. The third patient was admitted with a mass on the left side of the neck for one year. On evaluation, he was found to have left cervical lymphadenopathy, with its biopsy showing non-caseating epitheloid granuloma. Immunofluorescence did not show evidence of leukemia or lymphoma. All the patients had negative tuberculin skin tests and elevated serum angiotensinconverting enzyme levels supporting the diagnosis of sarcoidosis. They were treated with steroids with complete resolution of symptoms and no recurrence at follow-up. Sarcoidosis is an underdiagnosed entity in India. Thus, awareness of the atypical clinical features could lead to early recognition of the disease and its treatment.

A 22-year-old female presented with large swelling on the right subscapular region for two years duration. It gradually increased in size approximately 9 x 7 x 6 cm, situated in dorsal aspect of shoulder complex near the tip of scapula. Previously; she was operated for similar swelling of gluteal region two years back. There was no family history and trauma. General examination was within normal limit. Local examination showed large size, subcutaneous swelling involving the lateral border and angle of scapula, which was firm to hard in consistency, not adherent to underlying muscle. Rib cage and skin over the swelling appeared normal. It was associated with mild pain and tenderness.Blood investigations included complete blood count -normal, Hbs Ag -negative, HCV Ab -negative, HIV I and II -negative, serum creatinine -0.9 mg/dl, serum calcium -9.0 mg/dl, serum phosphorus 3.6mg/dl, serum PTH -56 ng/dl, Vit D-10 ng/dl, ALP -49.2mg/dl, serum uric acid -2.9 mg/ dl were within normal limits, except ESR -49mm (westergrens method) and CRP -15.7 mg/dl.CECT findings showed subcutaneous multiple, rounded opacities separated by radiolucent lines (fibrous septa), which lie outside the joint capsule [Table/ Fig-1]. Under general anaesthesia, the mass was removed enbloc with pseudocapsule and was sent for histopathological examination. Gross findings revealed a well-defined mass with spongy, cystic spaces filled with yellowish necrotic debris and thickened wall [Table/ Fig-2]. Microscopy showed cystic spaces filled with necrotic calcified material, lymphoplasmacytic infiltrate, fair number of histiocytic and multinucleated osteoclastic type giant cells [Table /Fig-3,4]. Causes that may be responsible for calcification like chronic renal failure, primary hyperparathyroidism and myositis ossificans were ruled out. So a final diagnosis of idiopathic Tumoral calcinosis was given. We followed up the patient and observed that there was no recurrence. CASE-2A single bony swelling over left dorsal aspect of feet and ankle region since 4 years was presented in a 49-year-old male . It was slowly growing over a long time and there was no history of trauma. On local examination, there was a bony hard swelling, free of overlying skin, mobile in mediolateral plane. Blood test results of complete blood count, serum calcium, phosphorus, creatinine, serum Parathormone (PTH), Antinuclear Antibody Test (ANA) which all were within normal limits.

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