Rare Scar Sarcoidosis: A Dermatologic Masquerader

Infiltration of sarcoid granuloma in old cutaneous scars is one of the uncommon cutaneous manifestations of sarcoidosis. Here we report the case of a 32-year-old female who presented with swelling and irritation in a 9-month-old appendicectomy scar. An incisional scar biopsy was done and it revealed non-caseating granuloma. On query she had inflammatory polyarthritis and persistent dry cough for last two months. High resolution CT (HRCT) revealed right paratracheal, both hilar, paraaortic, and subcarinal lymphadenopathy with pulmonary nodular densities in both lung fields. FNAC from mediastinal node revealed non-caseating granuloma consistent with sarcoidosis. Successful regression of cutaneous inflammation was achieved using a course of oral steroids, hydroxychloroquine and methotrexate. The incidence of scar sarcoidosis is rare and therefore not well-understood. However, inflammatory alterations in preexisting scars may be important indicators of disease onset. J Enam Med Col 2020; 10(2): 122-125

Novel Three-Dimensional Organoid Sarcoidosis Granuloma Model

Sarcoidosis is a multi-system disorder of granulomatous inflammation which most commonly affects the lungs. Its etiology and pathogenesis are not well defined in part due to the lack of reliable modeling. This article presents the development of a novel in vitro three-dimensional lung-on-chip organoid designed to mimic granuloma formation. A lung on chip fluidic macrodevice with three channels for cell culture insertion was developed and added to the previously developed a lung-on-membrane model. Granulomas were cultured from blood samples of patients with sarcoidosis and then inserted in the air-lung-interface (ALI) of the microchip to create a three-dimensional organoid sarcoidosis model (OSGM). The model was tested for cell viability with fibroblasts. We measured the cytokine profiles in medium of OSGM and compared with lung model without granuloma. Concentration of IL-1beta, Il-6, GM-CSF, and IFN-gamma were found significantly higher in OSGM group. The current model represents the first 3D OSGM created by adding a microfluidics system to a dual-chambered lung on membrane model and introducing developed sarcoid-granuloma to its ALI.

Isolated Ocular Sarcoidosis Mimicking Ring Melanoma

We report the case of a 25-year-old female, who presented with a large, pale tumor of her ciliary body that extended to >180° of the anterior chamber angle. All preoperative examinations including ultrasound biomicroscopy, scleral transillumination, and MRI indicated melanoma. A thorough systemic work-up was negative. A diagnosis of ring melanoma was suspected, and the patient was scheduled for enucleation. However, perioperative frozen section indicated granulomatous inflammation. The enucleation was cancelled, and a subtenon injection of triamcinolone was administered, which resulted in the disappearance of the tumor. Together, the findings meet the criteria for the diagnosis of isolated ocular sarcoidosis. This case demonstrates that a sarcoid granuloma can mimic all clinical features of a ring melanoma. Therefore, a biopsy should be done before destructive surgery is carried out.

Tattooist-Associated Tattoo Complications: “Overworked Tattoo,” “Pigment Overload” and Infections Producing Early and Late Adverse Events

Background: Tattooist-related technical failures of tattooing were hitherto unstudied and related to clinical complications. Tattooing requires talent, training and experience. Amateurism is a challenge in popular tattoo industry with no formal education and certification of the tattooists. Objective: To study technical tattoo failures causing disease in a consecutive hospital material of tattoo complications. Material: 574 patients with 702 tattoo complications referred to the “Tattoo Clinic” (a subspecialised dermatological clinic) were enrolled. Patients were examined clinically and classified with respect to the cause of complication. Results: 147 (21%) tattooist and tattoo studio-related complications were recorded, i.e. excessive pigment installed in the dermis with “pigment overload” in 64 (9%), tattoo “needle trauma” with “overworked tattoos” in 43 (6%), contaminated ink causing infection in 20 (3%), and other sources of infections related to tattooing in 20 (3%). Pain and discomfort were particularly common as well as long-term complications including scarring induced by “needle trauma.” “Pigment overload” with black pigment carried a special risk of granulomatous inflammation and sarcoid granuloma and was observed in 12/35 (34%) of punch biopsies taken from tattoos with “pigment overload.” Keratoacanthoma associated with trauma was observed in 1 case. 82% of complications were related to professional tattooists working in a tattoo studio and 18% to amateurs. Conclusion: Technical failures of tattooing are associated with medical tattoo complications. “Needle trauma” with major skin damage, e.g. “overworked tattoo,” and installation of excessive pigment, e.g. “pigment overload,” and (re)use of contaminated tattoo ink bottles are identified failures calling for preventive intervention.

Sarcoidosis in A. C. Milan (1899)?

The pathogenesis, diagnosis and therapy of sarcoidosis as an autonomous disease are subjects of spirited discussions, which haven’t found definitive conclusion yet. Distinguishing between sarcoidosis and sarcoid-like reactions (sarcoid - type granulomas) is not currently a medical “gold standard” and is not implemented in clinical practice. This leads to 1) misinterpretation of numerous available data; 2) difficulty in the interpretation of other unverified data, which is often followed by 3) inappropriate or inadequate therapeutic approach. Similarly to many other diseases, in sarcoidosis and sarcoid - types of reactions the concept of personalised approach and therapy should also be introduced. This methodology of clinical guidance is difficult, complex and not always achievable in the current medical status and relations (doctor-patient relationship; financial factor; time factor). It is appropriate to note that in some cases the guidelines or the so-called standards are neglected or not possible to put into practice with the aim of better therapeutic practices and strategies, as well as the achievement of optimal final clinical results (especially in patients with sarcoid granulomas). The sarcoid granuloma, even when it is sterile, should not be considered as the equivalent of sarcoidosis, i.e., sarcoidosis as an autonomous disease. Sure enough, exactly because of this fact, the personalised approach should not be an exception, but it has to gradually become a rule in medical practice. When clinical decisions are conformed to some of the latest modern concepts, officialised in the international databases, often the achieved results can be much better.We present a patient with a tattoo of AC Milan (1899) on his right arm, who subsequently developed localised sterile sarcoid granulomas in the area of the tattoo. Later the process became generalised on his whole body’s skin, lungs and lymph nodes. It is unclear for the moment whether this condition should be interpreted as sarcoidosis as an autonomous disease or, instead, as a sarcoidal type of reaction with subsequent generalisation due to cross-reactivity against antigens present in other tissues with similarities to the exogenous pigments. Following the modern concepts regarding the pathogenesis of these two conditions, we introduced, in this case, an innovative, non-standard approach: 1) systemic and local immunosuppressive therapy, combined with 2) recommеndation for immediate surgical excision of the tattoo to remove the possible trigger of molecular and antigen mimicry.

Solitary tentorial sarcoid granuloma associated with Propionibacterium acnes infection: case report

Sarcoidosis is a systemic granulomatous disease with unknown cause, which very rarely occurs exclusively in the central nervous system. The authors performed biopsy sampling of a mass that developed in the left tentorium cerebelli that appeared to be a malignant tumor. The mass was diagnosed as a sarcoid granuloma, which was confirmed with the onset of antibody reaction product against Propionibacterium acnes. Findings suggesting sarcoidosis to be an immune response to P. acnes infection have recently been reported, and they give insight for diagnosis and treatment of this disease. The authors report the possible first case that was confirmed with P. acnes infection in a meningeal lesion in solitary neurosarcoidosis.