Sarcoidosis with thyroid involvement, polymyalgia rheumatica and breast carcinoma. A case report

Löfgren Syndrome: Clinical Presentation, Clinical Course, and Literature Review

Löfgren syndrome is an acute presentation of sarcoidosis that comprises fever, bilateral and symmetric hilar lymphadenopathies, polyarthritis, and erythema. We present the case of a 34-year-old male patient who presented with ankle monoarthritis without a history of a traumatic event. Contralateral ankle arthritis associated with erythema nodosum and fever developed one week later. Laboratory tests showed anemia, thrombocytosis, and elevated inflammatory parameters. A chest CT revealed symmetrical mediastinal and hilar adenopathies. A transbronchial biopsy was compatible with granulomatous lymphadenitis, and the diagnosis of Löfgren syndrome was confirmed. Our case report and literature review emphasize the wide web of mimicry of acute sarcoidosis. Secondary forms of acute sarcoidosis are likely to benefit from additional and more complex immunomodulatory therapies. Close monitoring and follow-up should be conducted because it is possible that these patients experience higher rates of recurrence or relapse.

Concurrent Diagnoses of Cutaneous Sarcoidosis and Recurrent Metastatic Breast Cancer: More than a Coincidental Occurrence?

Sarcoidosis is a rare, chronic, multisystem disease of unknown aetiology, characterised by non-caseating epithelioid cell granulomas. Its association with internal malignancy, in particular haematological cancers has been strongly documented in the literature, while its link with solid organ malignancies is less extensively reported. We present an atypical case of cutaneous sarcoidosis occurring in association with breast cancer recurrence in a 49-year-old female. Physician recognition of this link between sarcoidosis and internal malignancy is vital because many cases of sarcoidosis in association with neoplasia present initially, or even exclusively, with cutaneous sarcoidal lesions that may precede the development of cancer by several years, or as in our case, present as a cutaneous marker of concomitant underlying malignancy. Our case highlights the importance of age-appropriate cancer screening in additional to a routine work-up for systemic sarcoidosis in a patient with cutaneous sarcoidosis.

Breast Cancer and Sarcoidosis: Case Series and Review of the Literature

BACKGROUND

Sarcoidosis is a chronic inflammatory disease of unknown etiology, which can involve different organs and systems. Accordingly, sarcoidosis can mimic breast cancer, making the differential diagnosis very difficult.

CASE REPORT

5 patients with a diagnosis of both sarcoidosis and breast cancer followed by the Rabin Medical Center between January 1993 and June 2012 were enrolled in this study. Additionally, a comprehensive literature review which identified 104 patients diagnosed with breast cancer and sarcoidosis was carried out. In both populations reviewed, the average age at diagnosis of sarcoidosis and breast cancer was 57 years. Among the 66 patients with both sarcoidosis and breast cancer, sarcoidosis preceded breast cancer in 31 cases, followed it in 23 cases, and appeared concurrently in 10 cases.

CONCLUSION

Based on our clinical cases and literature review, a histological study is recommended over imaging if sarcoidosis or breast cancer may be present. Furthermore, breast cancer is rarely associated with sarcoidosis or sarcoidosis-like reaction.

Multinucleated giant cells in fine-needle aspiration of thyroid nodules: their diagnostic significance

Multinucleated giant cells (MNGCs) are reported in many thyroid lesions. This study examines whether their quantity and quality can help in the differential diagnosis. All fine-needle aspirations (FNAs) of the thyroid with a "significant" number of MNGCs were reviewed from 1995 -1998. There were 23 cases (<1% of thyroid FNAs): 8 papillary carcinomas (PC), 4 subacute thyroiditis (ST), 3 granulomas, 7 adenomatous goiters (AG), and one Hurthle-cell adenoma (HA). MNGCs with dense cytoplasm were seen exclusively in PC, ST, and granulomas. They had angulated shapes. They were most numerous, largest, and with the highest number of nuclei in ST and granulomas. MNGCs with foamy cytoplasm were seen in AG and HA and 80% of the other cases (PC, ST, and granulomas). In PC, rare MNGCs had intranuclear inclusions and grooves. The accompanying cell population was characteristic of each disease. The quantity and quality of MNGCs in thyroid FNA may be helpful in narrowing the differential diagnosis. Diagn. Cytopathol. 1999;21:307-312.

Pathology of sarcoidosis

This article reviews the pathology of sarcoidosis that covers the general and systemic aspects of the disease. Macroscopic and microscopic descriptions of the disease process are given for selected organs.

Partial amino acid sequence analysis and variable subgroup determination (VH and VL) of a monoclonal rheumatoid factor derived from a rheumatoid arthritis patient

Continuous cell lines secreting monoclonal rheumatoid factors (RF) were derived from rheumatoid arthritis (RA) patients by cloning Epstein-Barr virus (EBV) transformed B cells and by hybridoma techniques. We studied five different clones with stable RF secretion. All were IgM, 4 kappa and 1 lambda. One of these clones, RFAN was extensively studied, and the partial amino acid sequences of the variable regions of both heavy and light chains were determined. After affinity purification, the IgM lambda RF antibody derived from the EBV clone was run under reducing conditions on SDS-polyacrylamide gel electrophoresis. The separated heavy and light chains were blotted and then sequenced by a gas-phase sequenator. The N-terminal sequence of the lambda light chain corresponded to that of the V lambda III subgroup. The heavy chain of the same IgM RF clone had a blocked N-terminus, but a cyanogen bromide peptide starting after methionine at position 82 showed a sequence typical of the VHIII subgroup. Heavy and light chains were also prepared by gel filtration after reduction and carboxymethylation from the same EBV clone made into a hybridoma. After this preparation, the heavy chain was not blocked and the N-terminal sequence confirmed that the heavy chain variable region belonged to the VHIII subgroup. We believe this to be the first amino acid sequence study of a monoclonal RF derived from the repertoire of an RA patient.

Lung cancer and chronic interstitial pneumonia associated with systemic sarcoidosis

Lung cancer and chronic interstitial pneumonia associated with systemic sarcoidosis was detected in a 66-year-old woman at autopsy. Histologically, hyalinized sarcoid lesions were scattered in cervical lymph nodes, thoracic lymph nodes, abdominal lymph nodes, and spleen. Scattered non-caseating epithelioid cell granulomas with giant cells were observed in both lungs demoting cancer and chronic interstitial pneumonia. A tumor mass occupying right hilar portion was well-differentiated squamous cell carcinoma involving right upper lobe and right hilar lymph nodes. In the lower lobe of the left lung, a small nodule of poorly differentiated squamous cell carcinoma was detected. Alveolar septa, especially in both lower lobes of the lungs were thickened diffusely with fibrosis, edema, and inflammatory cell infiltration. Alveolar cavities contained hyaline membrane and large mononuclear cells. Atypical bronchiolar epithelial proliferation and squamous metaplasia associated with squamous cell carcinoma were detected. The clinical and pathological characteristics among eight reported cases of lung cancer associated with sarcoidosis and three reported cases of interstitial pneumonia associated with sarcoidosis were reviewed separately. There is no report describing both lung cancer and chronic interstitial pneumonia associated with sarcoidosis.

Spontaneous release of leucocyte migration-inhibitory factor by mononuclear cells eluted from rheumatoid synovial tissue

Spontaneous leucocyte migration-inhibitory factor (LIF) was assayed by an indirect system in which mononuclear cells (MNC) eluted from rheumatoid synovial tissues or isolated from peripheral blood of normal donors were cultured without antigen. The supernatants from these cultures and control supernatants, heated to 80 degrees C for 30 min to destroy the LIF activity, were used in the test. In seven out of eleven rheumatoid arthritis patients the eluted synovial MNC produced LIF spontaneously, whereas none of the twelve normal blood donors showed any such production. The ability to show spontaneous LIF production was primarily seen in the joint tissues from sero-negative patients.

Rheumatoid synovial lymphocytes lack concanavalin-A-activated suppressor cell activity

Synovial lymphocytes eluted by enzyme treatment from eleven patients with rheumatoid arthritis (RA) were investigated for the presence of concanavalin A (Con A)-activated suppressor cell activity as compared with that of peripheral blood lymphocytes of twenty normal donors. In addition, two patients with psoriatic arthritis and juvenile rheumatoid arthritis (JRA) were also investigated. Synovial lymphocytes from the eleven RA patients showed a mean augmentation of 28 +/- 13.30, and thus clearly lacked suppressor activity, whereas the mean suppression in the lymphocytes from the twenty normal donors was 13 +/- 14.40. Synovial lymphocytes from one patient with JRA and one with psoriatic arthritis showed a normal suppressor activity.

Polymyalgia rheumatica and chronic lymphatic leukaemia

A patient with polymyalgia rheumatica (PMR) is reported in whom, at the time of diagnosis, the number of lymphocytes in peripheral blood and bone marrow was normal. Lymphocytic infiltration typical of PMR was detected in renal and muscle biopsy specimens, and a liver fine-needle aspirate contained an abnormal lymphocytic infiltration, probably leukaemic. The number of lymphocytes gradually increased in bone marrow and peripheral blood until, almost 5 years after PMR had been diagnosed, a typical picture of chronic lymphatic leukaemia (CLL) was observable. The significance of the reported combination is discussed. The possibility is pointed out that a CLL in progress must be suspected when persistent lymphocytosis occurs in a patient with typical PMR, even if initially the response to treatment with corticosteroids suggests that PMR is the sole disorder.