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Foreign Bodies in Granulomatous Cutaneous Lesions of Patients with Systemic Sarcoidosis

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Foreign Bodies in Granulomatous Cutaneous Lesions of Patients with Systemic Sarcoidosis STUDY Foreign Bodies in Granulomatous Cutaneous Lesions of Patients With Systemic Sarcoidosis Joaquim Marcoval, MD; Juan Man˜a´, MD; Abelardo Moreno, MD; Isabel Gallego, MD; Yolanda Fortun˜o, MD; Jordi Peyrı´, MD Objective: To assess the presence of foreign material demonstrated in 65 (15.3%) of 425 patients with sys- in the granulomatous cutaneous lesions of patients with temic sarcoidosis. In 14 (22%) of the 65 patients, the cu- systemic sarcoidosis. taneous biopsy specimen showed foreign particles in po- larized light. The skin lesions corresponded to 3 different Design and Setting: Observational study reevaluat- clinical patterns: an admixture of papules and infiltra- ing histological specimens at a university referral hos- tion of previously undetected minute scars (n=6); scar pital. sarcoidosis (n=4); and subcutaneous nodules (n=4). The lesions were located most frequently in the extremities, Patients: Sixty-five patients diagnosed as having sar- involving the knees in 10 patients. coidosis who developed granulomatous cutaneous in- volvement. Conclusions: The presence of polarizable foreign body material in granulomatous cutaneous lesions is not in- Main Outcome Measures: To detect the presence of frequent in patients with systemic sarcoidosis. Inocula- polarizable foreign particles in cutaneous biopsy speci- tion of foreign matter from a previous inapparent minor mens and to evaluate the association with clinical fea- trauma may induce granuloma formation in individuals tures of the patients. with sarcoidosis. Results: Granulomatous cutaneous involvement was Arch Dermatol. 2001;137:427-430 ARCOIDOSIS is a multisys- nificance of the presence of foreign bod- temic granulomatous dis- ies in granulomatous skin lesions of ease of unknown etiology that patients with sarcoidosis. With these con- involves mainly the lungs, siderations in mind, we reviewed the data mediastinal and peripheral Slymph nodes, eyes, and skin. The liver, For editorial comment spleen, salivary glands, heart, nervous sys- see page 485 tem, muscles, bones, and other organs may also be involved.1 The diagnosis is well es- in a series of patients with systemic sar- tablished when clinical and radiological coidosis and granulomatous cutaneous in- findings are supported by histological evi- volvement to ascertain the presence of for- dence of widespread noncaseous granu- eign body material in the skin biopsy lomas in 1 or more tissues or positive re- specimens and to reevaluate the clinical sults of a Kveim test.2 Because of its easy aspects. accessibility, the skin biopsy is of great value as a less-invasive diagnostic proce- RESULTS dure.1 The finding of polarizable foreign Of 425 patients diagnosed as having sys- matter in cutaneous epithelioid granulo- temic sarcoidosis, the biopsy specimens in From the Departments of mas traditionally permits the exclusion of 65 (15.3%) patients showed granuloma- Dermatology (Drs Marcoval, the diagnosis of sarcoidosis.3-5 However, tous cutaneous involvement. In 15 bi- Gallego, Fortun˜o, and Peyrı´), Internal Medicine (Dr Man˜a´), some cases have been reported in which opsy specimens obtained from 14 (22%) and Pathology (Dr Moreno), foreign particles were present in granulo- of the 65 patients, foreign particles were Hospital de Bellvitge, matous cutaneous lesions in patients with observed under polarized light. Of these University of Barcelona, well-demonstrated systemic sarcoid- 14 patients, there were 13 women and 1 Barcelona, Spain. osis.3,4,6 These findings questioned the sig- man (mean age, 50.3 years; range, 33-70 (REPRINTED) ARCH DERMATOL / VOL 137, APR 2001 WWW.ARCHDERMATOL.COM 427 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 years). The chest radiograph stages and extrathoracic in- volvement in these patients are shown in the Table. Only PATIENTS AND METHODS patient 3, who formerly took care of a garden, admitted to previous contact with cactus, and vegetal particles were During a 26-year period (1974-1999), 425 patients found in her skin lesions. None of the remaining pa- were diagnosed as having sarcoidosis at the Sarcoid tients had noticed the inoculation of exogenous mate- Clinic of the Hospital de Bellvitge, a 1000-bed teach- rial into the skin. ing institution in Barcelona, Spain. The diagnosis of We identified 3 types of cutaneous lesions showing sarcoidosis was made according to the classic crite- foreign particles: (1) an admixture of papules and previ- ria: a compatible clinical and radiological picture; his- ously undetected, infiltrated, minute scars located on the tological demonstration of noncaseous granulomas knees (n=5) (Figure 1) or discrete papules on the el- involving 1 or more tissues, with stains and cultures bow (n=1); (2) infiltration of previously known scars (scar negative for mycobacteria and fungi or positive re- sarcoidosis) involving the knees (n=4) (Figure 2); and sults of the Kveim test; and exclusion of other granu- (3) subcutaneous nodules involving the forearms (n=3) lomatous diseases. In patients whose tissue biopsy Figure 3 specimens did not provide histological confirma- ( ) and the face (n=1). In general, the lesions were tion, the diagnosis of sarcoidosis was accepted if the located more frequently in the extremities, involving the purified protein derivative of tuberculin test results knees (n=10), the arms (n=4), and the face (n=1). were negative, other diseases were excluded, and the Histologically, the lesions were noncaseous (sar- clinical course was consistent with sarcoidosis.7-9 We coid) granulomas involving the dermis, subcutis, or both, also accepted a diagnosis without a biopsy speci- with minor or no lymphocytic component at the periph- men when the intrathoracic gallium citrate Ga 67 up- ery. In the majority of cases, foreign material was de- take showed a lambda pattern (image resembling the tected by standard observation as amorphous or crystal- Greek letter produced by gallium uptake in the right loid material or was suspected when a hole in the vicinity paratracheal and bilateral hilar lymph nodes), with of giant cells was detected during tissue processing. The or without the panda image (image of the face of a panda produced by gallium uptake in the symmetri- presence of all foreign bodies was confirmed by exam- cal lacrimal and parotid glands).9-11 All patients with ining the specimen under polarized light. Figure 4 shows systemic sarcoidosis who had cutaneous lesions were a sarcoid granuloma with foreign particles, and Figure 5 evaluated at the Department of Dermatology. Skin bi- shows the same microscopic field under polarized light. opsies were performed when granulomatous cuta- neous involvement was clinically suspected. Those patients with histologically demonstrated granulo- COMMENT matous skin lesions were included in this study. We collected data about the stage of baseline radio- The presence of foreign particles in granulomatous cuta- graph and extrathoracic sarcoidosis and the history neous lesions was demonstrated in 14 (22%) of 65 pa- concerning inoculation of exogenous material into tients with systemic sarcoidosis and skin involvement. The the skin from all patients. Cutaneous biopsy speci- systemic character of the disease was well documented in mens with granulomatous involvement were reex- amined under polarized light to detect foreign par- all patients by the demonstration of intrathoracic and/or ticles. We excluded asteroid bodies, Schaumann extrathoracic disease, in addition to specific (granuloma- bodies, and the small refractive crystals of calcium tous) skin involvement. These results agreed with previ- carbonate usually encountered in sarcoidosis. ous reports by Walsh et al3 and Val-Bernal et al4 and cor- roborated the observation that foreign body granuloma and sarcoidosis are not mutually exclusive. Clinical Data of the Patients* Patient No./ Chest Age, y/Sex Extrathoracic Involvement Radiograph Stage Cutaneous Lesions Site 1/45/F Erythema nodosum II Papules, scars Knees 2/54/F . I Nodules Face 3/70/F . I Nodules Arms 4/37/M Axillary adenopathy II Nodules Arms 5/43/F Erythema nodosum, cutaneous plaques I Papules Right elbow 6/60/F Erythema nodosum II Scar Left knee 7/42/F Uveitis II Scar Right knee 8/58/F . 0† Nodules Arms, legs 9/53/F Erythema nodosum I Papules, scars Knees, elbows 10/70/F Erythema nodosum I Scar Right knee 11/33/F Erythema nodosum I Papules, scars Knees 12/33/F Erythema nodosum I Scar Right knee 13/53/F Erythema nodosum I Papules, scars Knees 14/53/F Erythema nodosum, uveitis 0 Papules, scars Knees *Ellipses indicate that there was no extrathoracic involvement. †Micronodular pattern shown in the results of high-resolution computed tomography. (REPRINTED) ARCH DERMATOL / VOL 137, APR 2001 WWW.ARCHDERMATOL.COM 428 ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/01/2021 Figure 1. Papules and scars on the knees in patient 1. Figure 4. Cutaneous biopsy specimen showing sarcoid granulomas and foreign particles (hematoxylin-eosin, original magnification 3400). Figure 2. Scar sarcoidosis in patient 7. Figure 5. The microscopic field shown in Figure 4 under polarized light. Based on a large series of patients with cutaneous sarcoidosis, Veien et al6 reported that foreign material was sometimes found in old cutaneous scars probably intro- duced as a consequence of the initial injury. The pro- pensity of cutaneous sarcoidosis to localize in tattoos has also been reported.12-16 More infrequently,
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