Verrucous Cutaneous Sarcoidosis

Abstract

Sarcoidosis is a multisystem disorder of unknown origin, characterized by the accumulation of lymphocytes and mononuclear histiocytes inducing the formation of noncaseating "naked" epithelioid granulomas. The lungs, lymphatic system, and skin are most often affected, but sarcoidosis may affect any organ. Cutaneous involvement of sarcoidosis is often the sentinel sign of the disease, with the skin sometimes being exclusively affected. We present a case of a 54-year-old African American woman with long-standing history of pulmonary sarcoidosis that presented with multiple verrucous cutaneous lesions on the upper and lower extremities mimicking carcinoma. The initial cutaneous biopsy was superficial in nature, and the pathologist raised the consideration of a possible keratoacanthoma. A deeper skin shave biopsy was performed, and the histopathology showed verrucous pseudoepitheliomatous epidermal hyperplasia with scattered noncaseating granulomas in the superficial dermis. Stains (acid-fast bacillus, Periodic acid-Schiff, and Gomori-Grocott methenamine silver stains) were negative for microorganisms. Given the clinical setting and histomorphology of the cutaneous lesions, the diagnosis of verrucous sarcoidosis was rendered. Verrucous sarcoidosis is a rare cutaneous manifestation of sarcoidosis that could be easily misdiagnosed if it is not appropriately biopsied. This hinders the precise evaluation of the histological specimen, overall clinical picture, and administration of appropriate therapy.

Clinical Manifestations of Sarcoidosis and Granulomatous Disorders

“…Usually, systemic sarcoidosis of other internal organs is present [47]. Lesions may be multiple exophytic, extensively verrucous yellowish-to-whitish lesions with a reddish-brown circinate border, size ranging from 1.0 to 2.0 cm in diameter [48].…”

Cutaneous Hematopathology

“…Lupus pernio refers to violaceous induration on the nose and cheeks which may result in signifi cant disfi guration (James 1992 ). Verrucous sarcoidosis is an uncommon variant which may mimic squamous cell carcinoma clinically (Stockman et al 2013 ). Another rare variant is syringotropic sarcoidosis, which presents as multiple erythematous patches or plaques on the lower extremities (Hayakawa et al 2013 ).…”

“…An interesting fi nding in the syringotropic variant was the profoundly decreased expression of dermcidin and aquaporin 5 in the affected sweat glands (Hayakawa et al 2013 ). In verrucous sarcoidosis, there is verrucous pseudoepitheliomatous hyperplasia of the overlying epidermis (Stockman et al 2013 ). A study has expanded the histologic spectrum of cutaneous sarcoidosis, including tuberculoid granulomas, interstitial granulomas, focal necrosis, and lichenoid infl ammation (Ball et al 2004 ).…”

Chronic verrucous plaques on bilateral lower extremities

“…Diagnosis requires a compatible clinical picture and histopathologic findings, in addition to the exclusion of similarly presenting diseases, specifically infection. 1 Granulomatous (vegetative) pyoderma gangrenosum—Incorrect. Although granulomatous pyoderma gangrenosum can have a verrucous appearance, it typically presents as superficial ulcerative lesions on the head and neck, with intra- or subepidermal granulomas rather than dermal granulomas, making this diagnosis less likely.…”

“…Diagnosis requires a compatible clinical picture and histopathologic findings, in addition to the exclusion of similarly presenting diseases, specifically infection. 1 …”