Frohse's arcade syndrome revealing sarcoidosic myopathy

Bilateral swelling of the forearms revealing muscular sarcoidosis: a case-based review

Muscular sarcoidosis is rarely symptomatic and mainly affects proximal muscles of the lower extremities. However, the distal localization in the upper extremities is rare. We used systematic approach to analyze all relevant literature review and we identified only three cases of muscular sarcoidosis of the upper extremities. We report the case of a 56-year-old woman who presented distal and bilateral swelling of the extensor surface of the forearms revealing muscular sarcoidosis. The laboratory exams associated elevated acute phase reactants with elevated serum angiotensin-converting enzyme levels and normal serum muscle enzymes. Ultrasound and MRI showed a bilateral and symmetrical muscle hypertrophy of the extensors of the fingers. Histological examination of muscle specimen and minor salivary gland biopsy revealed noncaseating epithelioid-cell granulomas. Therefore, the diagnosis of muscular sarcoidosis of the finger extensor muscles was made. Swelling of the forearms disappeared gradually under prednisolone 1 mg/kg/day. We used methotrexate as a steroid-sparing agent. Muscular MRI in sarcoidosis is not specific, but is to make a diagnosis of the lesion to optimize the biopsy which the cornerstone of the diagnosis ofsarcoidosis.

Musculoskeletal involvement in sarcoidosis

Sarcoidosis is a multisystem inflammatory disorder of unknown cause. It most commonly affects the pulmonary system but can also affect the musculoskeletal system, albeit less frequently. In patients with sarcoidosis, rheumatic involvement is polymorphic. It can be the presenting symptom of the disease or can appear during its progression. Articular involvement is dominated by nonspecific arthralgia, polyarthritis, and Löfgren's syndrome, which is defined as the presence of lung adenopathy, arthralgia (or arthritis), and erythema nodosum. Skeletal manifestations, especially dactylitis, appear mainly as complications of chronic, multiorgan sarcoidosis. Muscle involvement in sarcoidosis is rare and usually asymptomatic. The diagnosis of rheumatic sarcoidosis is based on X-ray findings and magnetic resonance imaging findings, although the definitive diagnosis is made by anatomopathological study of biopsy samples. Musculoskeletal involvement in sarcoidosis is generally relieved with nonsteroidal anti-inflammatory drugs or corticosteroids. In corticosteroid-resistant or -dependent forms of the disease, immunosuppressive therapy, such as treatment with methotrexate or anti-TNF-α, is employed. The aim of this review was to present an overview of the various types of osteoarticular and muscle involvement in sarcoidosis, focusing on their diagnosis and management.

Diagnosis and classification of granulomatous myositis

The term granulomatous myositis is applied to a myopathic syndrome associated with non-specific epithelioid granulomas in striated muscle. This rare entity is most frequently related to sarcoidosis, but other uncommon causes have been reported, including an idiopathic form only after systemic disorders known to cause similar myopathological abnormalities have been excluded. Symmetrical proximal or distal muscle weakness is the rule in the clinical presentation, sometimes associated with dysphagia. Although the clinical profile together with electromyography (EMG) studies may be useful, definite diagnosis requires pathological examination. Systemic glucocorticoids are the treatment of choice, but the clinical outcome is not always satisfactory.