Sarcoidosis in A. C. Milan (1899)?

Abstract

The pathogenesis, diagnosis and therapy of sarcoidosis as an autonomous disease are subjects of spirited discussions, which haven’t found definitive conclusion yet. Distinguishing between sarcoidosis and sarcoid-like reactions (sarcoid - type granulomas) is not currently a medical “gold standard” and is not implemented in clinical practice. This leads to 1) misinterpretation of numerous available data; 2) difficulty in the interpretation of other unverified data, which is often followed by 3) inappropriate or inadequate therapeutic approach. Similarly to many other diseases, in sarcoidosis and sarcoid - types of reactions the concept of personalised approach and therapy should also be introduced. This methodology of clinical guidance is difficult, complex and not always achievable in the current medical status and relations (doctor-patient relationship; financial factor; time factor). It is appropriate to note that in some cases the guidelines or the so-called standards are neglected or not possible to put into practice with the aim of better therapeutic practices and strategies, as well as the achievement of optimal final clinical results (especially in patients with sarcoid granulomas). The sarcoid granuloma, even when it is sterile, should not be considered as the equivalent of sarcoidosis, i.e., sarcoidosis as an autonomous disease. Sure enough, exactly because of this fact, the personalised approach should not be an exception, but it has to gradually become a rule in medical practice. When clinical decisions are conformed to some of the latest modern concepts, officialised in the international databases, often the achieved results can be much better.We present a patient with a tattoo of AC Milan (1899) on his right arm, who subsequently developed localised sterile sarcoid granulomas in the area of the tattoo. Later the process became generalised on his whole body’s skin, lungs and lymph nodes. It is unclear for the moment whether this condition should be interpreted as sarcoidosis as an autonomous disease or, instead, as a sarcoidal type of reaction with subsequent generalisation due to cross-reactivity against antigens present in other tissues with similarities to the exogenous pigments. Following the modern concepts regarding the pathogenesis of these two conditions, we introduced, in this case, an innovative, non-standard approach: 1) systemic and local immunosuppressive therapy, combined with 2) recommеndation for immediate surgical excision of the tattoo to remove the possible trigger of molecular and antigen mimicry.

Granulomatous slack skin mycosis fungoides developing simultaneously with sarcoid‐like lesions in a patient with repeated anabolic injections in the past?

“…In some cases, it is not possible to determine with full precision whether a lesion represents autonomous sarcoidosis or a sarcoid type of reaction (sarcoid-type granuloma), since a sarcoidal granuloma, even when it is sterile, cannot be considered the equivalent of sarcoidosis (Tchernev et al, 2018;Tchernev, Chokoeva, Wollina, & Lotti, 2015). It is believed that a large group of skin diseases can enter into the differential diagnosis of cutaneous sarcoid, including lymphomas and pseudolymphomas (Tchernev, Patterson, Nenoff, & Horn, 2010).…”

“…The absence of clearly established pathogenetic links in these patients reinforces the need for a personalized approach with a view to better therapeutic strategies and the achievement of optimal results (Tchernev et al, 2018). According to the literature, the treatment of granulomatous slack skin mycosis fungoides is not standardized, as possible options include (for example) corticosteroids, photochemotherapy, chemotherapy, and interferon alpha.…”

Tattoo pigment agglomerates measured in skin biopsies by computerised light microscopy

“…17 The delineation of the sarcoidosis entity of diseases of many manifestations reported in the medical literature lacks clarity, and no formal classification system has been developed. 9 Granulomas can have many forms and supposed reasons and associations. However, it is agreed that sarcoidosis in some 1/3 is manifested exclusively in the skin; 2/3 have predominant systemic organ manifestations, sometimes also associated with cutaneous F I G U R E 5 Allergic reactions in red tattoos with and without allergic cross-reactions, mean circularity index of agglomerates with 95% confidence intervals.…”

“…The pathomechanism of such reactions is suggested to be non‐allergic and due to foreign body reaction where the black pigment particles over time form agglomerates in the skin . Sarcoid reactions locally in the tattoo and systemic sarcoidosis in organs such as the lung and the eye have previously been described in relation to tattoos . Reactions in red‐pigmented tattoos typically occur due to an acquired allergy towards the red pigment with dermal inflammation resulting in distinct clinical reaction patterns namely plaque elevation, excessive hyperkeratosis and ulcero‐necrotic reaction .…”

“…7 Sarcoid reactions locally in the tattoo and systemic sarcoidosis in organs such as the lung and the eye have previously been described in relation to tattoos. [7][8][9][10][11] Reactions in red-pigmented tattoos typically occur due to an acquired allergy towards the red pigment with dermal inflammation resulting in distinct clinical reaction patterns namely plaque elevation, excessive hyperkeratosis and ulcero-necrotic reaction. 12,13 Allergic cross-reactions have been noted when a newly acquired red tattoo triggers allergic reaction in hitherto tolerated red tattoos located in other anatomical sites.…”