Sarcoidosis: radiographic manifestations in the nails and distal phalanges

A Single Nail Dystrophy as a Unique Manifestation of Sarcoidosis: A Case Report

Sarcoidosis with nail involvement is rare and most commonly affecting plural digits. Nail changes are frequently an indication of systemic disease and underlying bone involvement, thus complete clinical evaluation with bone and thorax radiological examination is a necessity in suspected cases. We report a case of onychodystrophy with osseous involvement of only one finger as unique manifestation of sarcoidosis, which is very rare.

Musculoskeletal Manifestations of Sarcoidosis: A Review Article

BACKGROUND

Sarcoidosis is a multisystem inflammatory disease with an etiology that is not clearly understood. Amongst the different organs that may be affected, the lungs are the most common. Musculoskeletal manifestations of the disease are uncommon.

OBJECTIVES

They include arthropathy, bone lesions, or myopathy, all of which may occur as initial symptoms or develop during the course of the disease.

METHODS

Articular involvement my present as arthralgia or arthritis. Skeletal complications usually develop in the chronic state of the disease. Muscular disease is rare and usually asymptomatic. Appropriate imaging modalities including X-ray, MRI, FDG-PET/CT assist in the diagnosis of rheumatic sarcoidosis. However, biopsy is necessary for definite diagnosis.

RESULT AND CONCLUSION

In most cases of musculoskeletal involvement, NSAIDs and corticosteroids are sufficient for symptomatic management. For more resistant cases immunosuppressive drugs (i.e., methotrexate) and TNF- inhibitors are used. Our aim is to review various types of musculoskeletal involvement in sarcoidosis and their existing treatment options.

Radiologic Manifestations of Musculoskeletal Sarcoidosis

PURPOSE OF REVIEW

The purpose of this review article is to present the spectrum of abnormalities and multi-modality imaging evaluations in patients with musculoskeletal sarcoidosis.

RECENT FINDINGS

The articular manifestations of sarcoidosis are difficult to distinguish from those of the other inflammatory and degenerative arthropathies, and the muscular lesions in sarcoidosis are generally clinically silent and therefore often missed. Magnetic resonance imaging has shown these manifestations to be very common in active sarcoidosis, and should thus be included in the screening if musculoskeletal sarcoidosis is suspected. The clinician should consider magnetic resonance imaging for the evaluation of patients with sarcoidosis who have unexplained osteoarticular complaints if standard radiographs are negative. Furthermore, radiologists should include sarcoidosis in the differential diagnosis of musculoskeletal disease detected at magnetic resonance imaging in the appropriate clinical setting.

Nail Sarcoidosis Presenting with Longitudinal Erythronychia

A 37-year-old woman presented with progressive longitudinal erythronychia and onychorrhexis of the toenails. She had a history of sarcoidosis of the lung and nose, which was silent without treatment at the time of presentation. Histopathological examination of a nail matrix biopsy revealed granulomas with palisading histiocytes in the connective tissue and a lymphocytic infiltrate in and around the granulomas without necrosis. Based on the clinical presentation, medical history, and histopathological examination, the diagnosis of nail sarcoidosis was made. Treatment with triamcinolone acetonide 40 mg/mL resulted in the disappearance of the onychorrhexis and a significant improvement of erythronychia. To our knowledge, a clinical presentation with longitudinal erythronychia as seen in our patient has not been previously described. Bone involvement of the underlying distal phalanges and systemic involvement can be paucisymptomatic but are present in most patients with sarcoidosis of the nails. Nail and bone involvement are both regarded as features of chronic and systemic sarcoidosis. Screening for bone and systemic involvement should be performed in all patients with nail sarcoidosis, as this may influence decisions on treatment and follow-up. Therefore, it is important to recognize longitudinal erythronychia as a possible clinical sign of nail sarcoidosis.

Sarcoidosis with prevalent and severe joint localization: a case report

Background

Sarcoidosis is a systemic granulomatous disease of unknown origin, characterized by the formation of granulomas without central necrosis. Each organ and tissue can be affected by the disease, but in most cases mainly the lungs and mediastinal lymph nodes but also skin, heart, eyes and joints are involved, the latter are mainly the metacarpophalangeal joints and bone lesions are often associated with involvement of the overlying skin. The diagnosis is often of exclusion, based on clinical and radiological suspicion, and should be confirmed by biopsy, although in each case it is necessary to exclude other possible causes of granulomatosis, including infections by mycobacteria. Here it is reported a case of particularly aggressive sarcoidosis with primitive involvement of the small joints of the hands and feet, and mediastinal lymph nodes.

Case presentation

The subject, a man, 60 years old, born in Morocco but living in Italy for many years, presented important involvement of bone structures and soft periarticular tissue, and was affected by the formation of granulomas without “caseum necrosis”. The painful symptoms and the skin ulceration had led to surgical amputation of the distal phalanges of most fingers of his hands and feet, but with subsequent resurgence of lesions in acral locations after surgery. The PET/CT scan showed an amount of radiotracer in mediastinal lymph nodes, while the lymph nodes sampled by TBNA were normal and the CD4/CD8 ratio was less than 3 in the bronchoalveolar lavage. We ruled out any possible infectious cause, including mycobacterial infection (both tubercular and atypical), so the patient was treated with systemic corticosteroids, with an excellent clinical and radiological response.

Conclusions

Such a case shows how the disease can have variable expressions, without primitive lung involvement; therefore, it should be necessary to consider any possible, unpredictable localization of the disease.