Cutaneous sarcoid‐like granulomas with alveolar hemorrhage and c‐ANCA PR‐3

Abstract

A 28‐year‐old woman, employed as a leather factory worker, noted asymptomatic, well‐delimited plaques on both knees, 6 years ago. The plaques were violaceous with a smooth surface. One appeared over a post‐traumatic scar from childhood (Fig. 1). Two years later, she began to complain of symptoms suggestive of polyarthritis, first of the small joints of the hands (proximal interphalanges) and then of the larger joints (wrists, elbows, and knees). She was diagnosed with rheumatoid arthritis and began treatment with nonsteroidal anti‐inflammatory drugs for 1 month without any change. Deflazacort, 12 mg/day, and hydroxychloroquine, 400 mg/day, were administered for 3 months, with improvement of her articular complaints, but not her skin lesions. 1 Well‐delimited, violaceous plaques with a smooth surface on the knees, one over an old post‐traumatic scar One year later, she complained of dysphonia, which remitted spontaneously after some weeks. After one additional year, she noted papules, with similar characteristics to the plaques, on the elbows, and two well‐delimited orange‐to‐brown plaques on the forehead (Fig. 2). 2 Orange–brown plaques symmetrically placed on the forehead During the fifth year of the disease, she was referred for the first time to a dermatologist, who biopsied one of the knee lesions. The histologic result was compatible with “sarcoid granuloma.” At that time, she presented with skin lesions as her only complaint. Sarcoidosis was suspected based on a chest X‐ray, which revealed hilar lymphadenopathy and diffuse accentuation of the interstitium. In November 2000, she suddenly developed fever (40 °C), cough with hemoptysis, dysphonia, and subcutaneous nodules on the palmar surface of the fingers of both hands that were painless, well‐delimited, 5 mm in diameter, and firm (Fig. 3). She reported a weight loss of 12 kg in the previous 3 months. Pulmonary condensation was found on auscultation, and she had palpable hepatomegaly. Peripheral lymphadenopathy was not present. 3 Painless, well‐delimited, firm subcutaneous nodules on the palmar surface of the fingers Laboratory investigations revealed normochromic, normocytic anemia (hemoglobin, 7.7 g/dL), iron deficit, a white blood cell count of 16,000/µL with neutrophilia, an erythrocyte sedimentation rate of 130 mm/h, elevation of liver enzymes, a slight increase in angiotensin‐converting enzyme (ACE) level (72 U/L), hypergammaglobulinemia (IgG, 3350 mg/dL), antinuclear antibody (ANA) of 1 : 320, and a slight increase in CD4 and decrease in CD8 lymphocytes with normal cellular morphology in blood. Renal function, urine sediment, urine and serum calcium, complement (C4), dsDNA, antimitochondrial antibody, direct and indirect Coombs test, antineutrophil cytoplasmic antibody (ANCA), tuberculin skin tests, viral markers of hepatitis B, C, and human immunodeficiency virus (HIV), electrocardiogram (ECG), ophthalmic examinations, and culture for infectious agents in blood and sputum were all normal or negative. Computed tomography (CT) scan showed an ...

A case of sarcoidosis mimicking Wegener’s granulomatosis

“…In contrast to this report, Rocha et al. 6 reported a case of sarcoidosis of five years’ evolution, which eventually developed features of WG. Sequential development of sarcoidosis and WG is very rare but has been reported; one by Ullrich et al.…”

The granulomatous reaction pattern

“…96 It has also followed BCG vaccination. They include B-cell chronic lymphocytic leukemia, 110 cutaneous lymphoma, 111,112 pyoderma gangrenosum, 113 hypoparathyroidism, 114 cryptococcal infection, 115 dermatomyositis, 116 primary biliary cirrhosis, 117 autoimmune thyroiditis and/or vitiligo, 118-120 polycythemia vera, 121 Wegener's granulomatosis, 122 and HIV infection. Skin lesions may occur in scars [98][99][100][101] following trauma (including surgery, desensitizing injection sites, and venepuncture), [102][103][104] cosmetic tattoos, 105,106 radiation, and chronic infection.…”