Article Text

Sarcoidosis presenting as a cutaneous eyelid mass
  1. MATTEO CACCIATORI
  1. Department of Ophthalmology, Princess Alexandra Eye Pavilion, Edinburgh
  2. Department of Pathology, University of Edinburgh
  3. Department of Ophthalmology, Princess Alexandra Eye Pavilion, Edinburgh
  1. KATHRYN M McLAREN
  1. Department of Ophthalmology, Princess Alexandra Eye Pavilion, Edinburgh
  2. Department of Pathology, University of Edinburgh
  3. Department of Ophthalmology, Princess Alexandra Eye Pavilion, Edinburgh
  1. PATRICK P KEARNS
  1. Department of Ophthalmology, Princess Alexandra Eye Pavilion, Edinburgh
  2. Department of Pathology, University of Edinburgh
  3. Department of Ophthalmology, Princess Alexandra Eye Pavilion, Edinburgh
  1. Dr Patrick Kearns, Princess Alexandra Eye Pavilion, Chalmers Street, Edinburgh EH3 9HA.

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Editor,—Sarcoidosis is a multisystem granulomatous disorder of unknown aetiology, most commonly affecting young adults and presenting most frequently with bilateral lymphadenopathy, with or without pulmonary infiltration, and with skin or eye lesions. Cutaneous involvement is present in 25% of patients with chronic sarcoidosis and 11% of patients without ocular sarcoidosis.1 We report a patient with unilateral palpebral sarcoid but without any other evidence of ocular or cutaneous sarcoidosis.

CASE REPORT

A 65-year-old woman presented with a large, firm non-tender cutaneous mass involving the left lateral canthus (Fig 1). It had developed over a 6 week period. The lesion first presented in the lateral quarter of the left upper lid and then extended to the lower lid.

Figure 1

Cutaneous mass involving the lateral canthus, the upper and lower lid.

She denied any systemic symptoms and physical examination was unremarkable. Ophthalmic examination showed a best corrected visual acuity of 6/6 in each eye. A discrete, large, prominent cutaneous mass without erythema was present in the lateral canthus, involving the upper and lower eyelids. Results of slit-lamp and fundus examination were normal. A biopsy specimen of the mass was obtained. Microscopic examination revealed the presence of non-caseating granulomata of epithelioid cell type with multinucleate cells (Figs 2 and 3). Stains for acid fast bacilli and fungi were negative. Serum angiotensin converting enzyme (ACE) level was 113 U/1 (range 3–75 U/l). A skin test with purified protein derivative (PPD) was non-reactive. Chestx ray showed the presence of an enlarged lobular contour at the right hilum indicating lymph node enlargement and some non-specific opacification in the right mid zone suggestive of pulmonary infiltration or scarring (grade II involvement).

Figure 2

Discrete granulomata occupy the entire dermis in the incisional biopsy.

Figure 3

Typical sarcoid granulomata with epithelioid and multinucleate cells.

The lesion remained unchanged for several months as treatment was delayed in the hope that spontaneous resolution would occur. However, in the absence of any significant change, the lesion was injected with Depo-Medrone (methylprednisolone), which produced a reduction in size. Despite this, a repeat biopsy after 9 months revealed persistence of active granulomatous reaction.

COMMENT

In this case sarcoidosis was diagnosed on the basis of histological evidence of non-caseating granulomata, negative culture for acid fast bacilli or fungi, the high serum level of ACE, anergy to PPD, and routine chest roentgenography.

The prevalence of ophthalmic manifestation in sarcoidosis is 22%.1 Ocular involvement includes anterior and posterior uveitis, secondary glaucoma, cataracts, lesions of lacrimal gland, conjunctiva, cornea, sclera, and optic nerve.2 Eyelid nodules are present in 3% of the patients with chronic sarcoid.3 The most common manifestations are small papules,1 though papular eruptions, larger nodules, lupus pernio, ulcerated nodules, and plaques and swollen eyelids have been reported.2 The ocular and adnexal involvement is more easily recognised in a patient with known sarcoidosis. The localised eyelid involvement seen in our patient, as a presenting feature of sarcoidosis, is an unreported finding.

Intralesional corticosteroid injection appears to be the only useful treatment of cosmetically disfiguring sarcoid eruptions.4Recurrence of cutaneous lesions after treatment with systemic corticosteroid therapy has been reported before.2

References

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