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Case Reports

Abstract

A 68-year-old male smoker was admitted for worsening shortness of breath and weakness with a 10-month history of erythroderma and 30-pound unintentional weight loss. Skin biopsy 9 months prior had shown spongiotic dermatitis.  Exam showed widespread, confluent bright pink patches and thin plaques, as well as axillary and inguinal lymphadenopathy.  CT chest additionally demonstrated hilar and mediastinal lymphadenopathy.  Due to concern for cutaneous T-cell lymphoma, two 4mm punch biopsies were performed. Both specimens demonstrated non-caseating dermal granulomas with sparse associated dermal and intraepidermal lymphocytes. Immunohistochemical staining demonstrated scattered small intraepidermal lymphocytes positive for CD3, CD2, CD5, and CD7, with a CD8:CD4 ratio of 10:1.   Both specimens were negative for a clonal TCR gene rearrangement.  GMS, AFB, and Fite stains were negative.  Bacterial and fungal tissue cultures were negative.  Peripheral blood flow cytometry showed no atypical T-cell population.   Serum ACE level was elevated.  Needle biopsy of an axillary lymph node and excisional biopsy of multiple groin lymph nodes showed non-necrotizing granulomatous lymphadenitis.   A diagnosis of erythrodermic sarcoidosis was favored, and prednisone was initiated.   One week later, a CT of the abdomen showed multiple hepatic masses, and needle biopsy showed metastatic small cell carcinoma of uncertain primary.   After discussion of therapeutic options, the patient opted for hospice, and died within one week.  Erythrodermic sarcoidosis is rare, with only 11 cases reported in the literature.   Sarcoidosis can occasionally occur in association with a variety of internal malignancies, and separating lesions of sarcoidosis from metastatic cancer can be clinically and radiographically challenging.