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A swollen, red scar
Case Report
A swollen, red scar Marenza Leo, Aldo Pinchera, Emilio Fiore, Elisa Giustarini, Claudio Giani Lancet 2007; 370: 456 Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy (M Leo MD, Prof A Pinchera MD, E Fiore MD, E Giustarini MD, Prof C Giani MD) Correspondence to: Dr Emilio Fiore, Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy e.fi[email protected]
456
In April, 2006, a 55-year-old woman was referred to our department with redness, swelling, and severe pain at the front of the neck, below the cricoid cartilage. Her symptoms had started a few months previously, and had gradually worsened since. In 1982, the patient had been diagnosed with a euthyroid multinodular goitre; one nodule had compressed her trachea, so she had undergone a partial thyroidectomy. She had been prescribed thyroxine ever since. She had no other medical history of note. The patient’s previous thyroid disorder, anterior neck pain, and swelling led to a provisional diagnosis, on referral, of acute thyroiditis. Physical examination showed that the swelling and redness were largely confined to the scar left by the previous partial thyroidectomy (figure). The thyroid was enlarged; a 30 mm nodule was detected in the right lobe. Cytological examination of the nodule showed that it was a thyroid adenoma; there was no evidence of inflammation. Blood tests—including a full blood count, routine biochemistry tests, thyroid function tests, and inflammatory markers—gave entirely normal results. Ultrasonography and CT of the neck showed nothing of note, other than the scar. A biopsy of the scar was done. Histopathological examination of the sample showed non-caseating granulomas, consisting of epithelioid cells, multinucleated Langhans’ giant cells, and a rim of lymphocytes. These findings were diagnostic of sarcoidosis. Chest radiography showed bilateral enlargement of the hilar lymph nodes; CT of the chest confirmed this finding, and showed peripheral pulmonary infiltrates. The results of lung function tests were normal; a Mantoux test was negative. A gallium-67 total body scan showed increased uptake of the tracer, in the regions of the neck scar and the hilar lymph nodes. However, serum concentrations of angiotensin-converting enzyme and lysozyme were normal. Moreover, the patient’s lung function was normal—and there was no evidence of uveitis, hypercalcaemia, or neurological or cardiac manifestations of sarcoidosis. We therefore decided not to prescribe steroid treatment. Nonetheless, the redness and swelling of the scar decreased strikingly over the next 3 months. Chest radiography showed that the bilateral hilar lymphadenopathy had also undergone partial spontaneous remission. Sarcoidosis is a multi-system disease of unknown cause.1 Skin manifestations have been reported in
Figure: Sarcoidosis of a scar (A) On inspection. (B) On CT.
20–35% of cases. The best known skin manifestations of sarcoidosis are probably erythema nodosum and lupus pernio. By contrast, scar sarcoidosis is rare, occurring in 2% of patients with sarcoidosis.2 Scar sarcoidosis can occur after physical trauma, including an injection or a tattoo;3,4 it can also be the first manifestation of more widespread disease.2 References 1 Morhenn VB, Smoller BR. Immunophenotyping of a sarcoidal granuloma in a scar, a manifestation of a possible autoimmune process. J Cutan Med Surg 1998; 3: 46–48. 2 Tchernev G. Cutaneous sarcoidosis: the “great imitator”: etiopathogenesis, morphology, differential diagnosis, and clinical management. Am J Clin Dermatol 2006; 7: 375–82. 3 Sorabjee JS, Garje R. Reactivation of old scars: inevitably sarcoid. Postgrad Med J 2005; 81: 60–61. 4 Dickinson JA. Sarcoidal reactions in tattoos. Arch Dermatol 1969; 100: 315–19.
www.thelancet.com Vol 370 August 4, 2007
A swollen, red scar Marenza Leo, Aldo Pinchera, Emilio Fiore, Elisa Giustarini, Claudio Giani Lancet 2007; 370: 456 Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy (M Leo MD, Prof A Pinchera MD, E Fiore MD, E Giustarini MD, Prof C Giani MD) Correspondence to: Dr Emilio Fiore, Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy e.fi[email protected]
456
In April, 2006, a 55-year-old woman was referred to our department with redness, swelling, and severe pain at the front of the neck, below the cricoid cartilage. Her symptoms had started a few months previously, and had gradually worsened since. In 1982, the patient had been diagnosed with a euthyroid multinodular goitre; one nodule had compressed her trachea, so she had undergone a partial thyroidectomy. She had been prescribed thyroxine ever since. She had no other medical history of note. The patient’s previous thyroid disorder, anterior neck pain, and swelling led to a provisional diagnosis, on referral, of acute thyroiditis. Physical examination showed that the swelling and redness were largely confined to the scar left by the previous partial thyroidectomy (figure). The thyroid was enlarged; a 30 mm nodule was detected in the right lobe. Cytological examination of the nodule showed that it was a thyroid adenoma; there was no evidence of inflammation. Blood tests—including a full blood count, routine biochemistry tests, thyroid function tests, and inflammatory markers—gave entirely normal results. Ultrasonography and CT of the neck showed nothing of note, other than the scar. A biopsy of the scar was done. Histopathological examination of the sample showed non-caseating granulomas, consisting of epithelioid cells, multinucleated Langhans’ giant cells, and a rim of lymphocytes. These findings were diagnostic of sarcoidosis. Chest radiography showed bilateral enlargement of the hilar lymph nodes; CT of the chest confirmed this finding, and showed peripheral pulmonary infiltrates. The results of lung function tests were normal; a Mantoux test was negative. A gallium-67 total body scan showed increased uptake of the tracer, in the regions of the neck scar and the hilar lymph nodes. However, serum concentrations of angiotensin-converting enzyme and lysozyme were normal. Moreover, the patient’s lung function was normal—and there was no evidence of uveitis, hypercalcaemia, or neurological or cardiac manifestations of sarcoidosis. We therefore decided not to prescribe steroid treatment. Nonetheless, the redness and swelling of the scar decreased strikingly over the next 3 months. Chest radiography showed that the bilateral hilar lymphadenopathy had also undergone partial spontaneous remission. Sarcoidosis is a multi-system disease of unknown cause.1 Skin manifestations have been reported in
Figure: Sarcoidosis of a scar (A) On inspection. (B) On CT.
20–35% of cases. The best known skin manifestations of sarcoidosis are probably erythema nodosum and lupus pernio. By contrast, scar sarcoidosis is rare, occurring in 2% of patients with sarcoidosis.2 Scar sarcoidosis can occur after physical trauma, including an injection or a tattoo;3,4 it can also be the first manifestation of more widespread disease.2 References 1 Morhenn VB, Smoller BR. Immunophenotyping of a sarcoidal granuloma in a scar, a manifestation of a possible autoimmune process. J Cutan Med Surg 1998; 3: 46–48. 2 Tchernev G. Cutaneous sarcoidosis: the “great imitator”: etiopathogenesis, morphology, differential diagnosis, and clinical management. Am J Clin Dermatol 2006; 7: 375–82. 3 Sorabjee JS, Garje R. Reactivation of old scars: inevitably sarcoid. Postgrad Med J 2005; 81: 60–61. 4 Dickinson JA. Sarcoidal reactions in tattoos. Arch Dermatol 1969; 100: 315–19.
www.thelancet.com Vol 370 August 4, 2007