A 40-year-old man not awayed with ...

A 40-year-old man not awayed with erythematous and lavender nodules, as well as ulcerations in succession the nasal and malar areas of his face (see accompanying figure). These lesions had slowly enlarged during the previous eight years. His initial presentation was remarkable alone for an erythematous papule to the right of the nose that was resistant to steroid treatment. He denied other symptoms, including itching or pain from the lesion, fatigue, shortness of breath, heat chills, weight loss, or arthralgias. The patient had no ill contacts and no known immunocompromised state. Physical examination was remarkable solitary for the facial lesions. Chest radiograph was within normal limits without infiltrates or hilar fullnes Biopsy of a facial lesion showed epithelioid, noncaseating granulomas.

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Question

Based in succession the patient's history and physical examination, which single of the following is the correct diagnosis?

[] A. Secondary syphilis. [] B Lepromatous leprosy [] C Cutaneous tuberculosis. [] D Cutaneous sarcoidosis. [] E Discoid lupus erythematosus.

Discussion

The answer is D: cutaneous sarcoidosis. Cutaneous sarcoidosis happens in 20 to 35 percent of patients with sarcoidosis. Cutaneous lesions fall into sum of two units categories: specific and nonspecific. Specific lesions include plaques, papules, nodules, scarring, or ulcerative lesions. Typically, they are brown r or purple lesions. (1) Erythema nodosum is the greatest in number common nonspecific manifestation. The diagnosis of cutaneous sarcoidosis is based onward its histologic appearance in the setting of typical systemic involvement. Symptoms include peripheral lymphadenopathy, fatigue, weight los dyspnea in succession exertion, shortness of breath, or cough Chest radiograph repeatedly reveals hilar lymphadenopathy in sarcoidosis. Biopsy of the skin reveals the classic noncaseating sarcoid granulomas. (1) Treatment may include systemic steroids, intralesional steroid injection, antimalarials, or methotrexate.

The differential diagnosis in this case includes secondary syphilis, lepromatous leprosy cutaneous tuberculosis, and discoid lupus erythematosus. Secondary syphilis is characterized by dint of scaling red-brown papules and plaques, typically smaller and flatter than those seen in this patient. The rash of secondary syphilis may appear anywhere in succession the body, including the palms and singles Skin lesions appear six to 12 weeks following the primary chancre and last four to six weeks. (2) Other used by all symptoms of syphilis at this stage include lymphadenopathy, excitement and arthralgias. Dark-field microscopic examination of a swabbed sample from the chancre may reveal the vicinity of vibrating spirochetes, but this is technically difficult and the chancre frequently has resolved by this stage. (2) Serologic testing is the usual means through which secondary syphilis is confirmed.

Lepromatous leprosy caused through the organism Mycobacterium leprae, is characterized on nondescript brown or red papules or plaques that commonly affect the ears and nose. Nodules also may bring to maturity These lesions are usually bilateral, symmetric, and painful. (2) repeatedly biopsy of the skin is diagnostic. Granulomas and acid-fast bacilli are noted.

nearest on the differential is cutaneous tuberculosis, of which lupus vulgaris is the most numerous common type. It is characterized from groups of reddish-brown nodules that have an "apple-jelly" color when blanched. (3) Lupus vulgaris frequently is found on the face. Ulceration and scarring may present itself On biopsy, the physician may descry caseating necrosis, epithelioid cells, Langerhans' giant confined apartments and lymphocytes. Acid-fast bacilli are rarely seen tillage of lesions or polymerase chain reaction can be used to identify mycobacteria.3 The systemic manifestations of tuberculosis assist in differentiating this disease from sarcoidosis.

Discoid lupus erythematosus is a chronic disease characterized according to inflammatory, scarring lesions. It has been reported that 20 percent of patients with systemic lupus erythematosus will lay open discoid skin lesions; however, most numerous patients who have only cutaneous lupus at presentation will not progres to systemic disease. The classic presentation is an inflammatory plaque with scaling, follicular plugging, telangiectasias, atrophic scarring, and central hypopigmentation. (4) everyday sites of involvement include the face, scalp, and ears. Skin biopsy typically reveals hyperkeratosis and follicular plugging, with superficial and sagacious lymphocytic infiltrates. Direct immunofluorescence of lesions characteristically exhibits immunoglobulin and complement deposition at the dermal-epidermal junction. (4)

The opinions and assertions contained herein are the private views of the authors and are not to be constru as official or as reflecting the views of the U Navy Medical Department or the U Navy Service at large.

REFERENCES

(1) Albertini JG Tyler W Miller OF 3rd Ulcerative sarcoidosis. Case report and review of the literature. Arch Dermatol 1997;133:215-9