Spot The Diagnosis 2

Hema M MD, DM,
Senior Assistant Professor of Rheumatology
Stanley Medical College, Chennai, India

63 year old male, a known diabetic presented with complaints of skin lesions over nose, face and around lips. Patient had recently been diagnosed to have miliary TB for which he completed ATT. The skin lesions were fleshy brown papules and nodules that appeared over the nostrils then progressed to over lips, cheeks. A biopsy was taken from a skin lesion over the infraorbital region; it revealed features suggestive of tuberculosis verrucous cutis. A repeat biopsy was planned since there was no resolution even after completion of ATT. A CT chest was done.

Whats the diagnosis?

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Sarcoidosis

Figure A : Shows lupus pernio
Figure B: B/L hilar adenopathy
Figure C : Galaxy sign : Coalescent granuloma with fissural nodularity- Closest differential diagnosis is military TB
The repeat biopsy revealed non-caseating granulomas, with epitheloid cells, foamy macrophages and Langland type of giant cells. The biopsy staining was negative for acid fast bacilli. Patient was diagnosed as a case of Sarcoidosis and was treated with steroids and Methotrexate. Over 6 months there has been complete resolution of the skin lesions and radiological resolution in the follow up CT. This case highlights that when the disease does not respond to conventional treatment; hold up and search for an alternative diagnosis.