A Rare Case of Pulmonary Sarcoidosis Presenting as Cutaneous Eyelid Granuloma as its Initial Manifestation
Author(s): Quratulain Fatima Masood
Abstract
Introduction: Sarcoidosis most commonly affecting young adults specifically adolescents are a systemic disease having an insidious onset frequently
presenting with lymphadenopathy as well as pulmonary infiltration. Diagnosis is usually incidental on routine chest radiography. Diagnosis
is usually established by the presence of epitheloid cell granulomas which is noncaseating and are negative for acid fast bacilli test which
differentiates these from caseating tuberculous granulomas. Here we present an unusual case having cutaneous eyelid granuloma as initial
manifestation of pulmonary sarcoidosis.
Case Presentation: A 65 year old African American female with past medical history of Asthma and seasonal allergies initially presented to the
dermatology clinic for skin colored nodular lesion on her right eyelid measuring 1.8cm in diameter, for which she was referred to Ophthalmology
where she underwent orbitotomy for removal of lesion. Biopsy was conducted which revealed the lesion to be non-caseating granuloma suggesting
the diagnosis of sarcoidosis. GMS and AFB stains were done which came out to be negative. For evaluation of pulmonary sarcoidosis, she
was referred to the pulmonary clinic. Patient is a known case of Asthma which was managed with inhaled corticosteroids (Symbicort 1 puff BID)
and Albuterol inhaler (as needed). Patient also reported of having chronic productive cough with white sputum and exertional dyspnea for last 6
months. Her family history is significant for COPD related to her sister but otherwise there is no other significant family history of lung diseases.
She denied having arthralgia, hemoptysis or weight loss. Her CT chest showed presence of mildly enlarged lymph nodes in the hilar and mediastinal
chains, largest measuring 16mm in diameter in the right hilum. No other suspicious lesions were present. Bronchoscopy with transbronchial
FNA (Fine Needle Aspiration) at the subcarnial and paratracheal lymph nodes was performed. No endobronchial lesion were noted. The diagnosis
of sarcoidosis in patient was confirmed by Needle aspiration biopsy that showed presence of non-necrotizing granulomatous inflammation. After
weighting the risks and benefits, patient opted to hold off on systemic corticosteroids for now, while we continue to monitor her disease course.
Discussion: Although Sarcoidosis is a systemic, idiopathic disease presenting with cutaneous manifestation in almost 25% of cases, however it
is rare for a patient to be reported with millet-seed nodules on eyelids as initial manifestation of sarcoidosis, which was present in our case.The
epidermal changes are also found in many patients with atrophy and parakeratosis. Diagnosis of sarcoidosis was made by exclusion by ruling out
differentials including rosacea, tuberculoid leprosy, inflammatory bowel disorder such as Crohn’s disease and granulomatous diseases. Pulmonary
involvement as bilateral hilar lymphadenopathy is also present in most of patient’s cutaneous sarcoidosis.
Our case is unique and different as compared to already documented several cases on sarcoidosis with isolated cutaneous involvement as it
presented as involvement of eyelids which is not considered as a typical presentation of a sarcoidosis patient. It is not easy to determine whether
isolated cutaneous sarcoidosis with no systemic manifestation should be considered as separate disease. However, study of Ingber and Klinken
concluded that scar sarcoidosis can be early indication of systemic sarcoidosis.