The Journal of the Arkansas Medical Society Issue 3 Vol 115 | Page 22

Special Section: Short Dermatological Cases
Derm Dilemma
Blake St. Clair, M3; Kevin St. Clair, MD
T
his 58-year-old woman pre-
sented with a 10-month history
of an asymptomatic indurated
dermal nodule of the nasal septum. No
other pertinent cutaneous findings were noted,
and the patient enjoys good general health.
A biopsy was taken for routine histology and
tissue culture. Hematoxylin and eosin staining
demonstrated non-caseating granulomatous
inflammation of the dermis. Neither acid fast
bacilli nor deep fungi were detected in the bi-
opsy specimen or tissue culture.
What is the next appropriate step in evalu-
ation or treatment of this patient?
A. Excision utilizing the Mohs technique
(margin control using frozen tissue
sections)
B. Standard surgical excision with margin
control via formalin fixed permanent
tissue sections
C. Imaging of the maxillary and frontal
sinuses with CT or MRI
D. Chest radiography
E. Sputum culture
Answer: D. Chest Radiography
Non-caseating granulomatous inflam-
mation accompanied by negative tissue
stains and cultures is typical of sarcoidosis.
Sarcoidosis is a multiorgan disease of un-
known etiology characterized by a chronic
cell-mediated immune response to an un-
known antigen. The lungs and intrathoracic
lymph nodes are most commonly affected;
approximately 25% of patients have cutane-
ous involvement. This patient exhibits prob-
ably the most specific skin manifestation:
lupus pernio. Other integumentary findings
include panniculitis of the lower legs (as-
sociated with Lofgren’s syndrome), purple-
dusky red plaques, or deeper subcutaneous
nodules.
70 • THE JOURNAL OF THE ARKANSAS MEDICAL SOCIETY
Most patients, symptomatic or not, ex-
perience some degree of pulmonary involve-
ment, ranging from bilateral hilar adenopathy
to parenchymal infiltrates to fibrosis. Chest
radiography is essential when beginning the
work up of a patient with presumptive sar-
coidosis.
VOLUME 115