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Case Reports

Abstract

Cutaneous sarcoidosis occurs in about 25% of sarcoidosis cases. However, xanthoma-like lesions are rare and can mimic metabolic or histiocytic disorders. We present a rare case of xanthoma-like yellow papules in which biopsy later confirmed multisystem sarcoidosis. 

A 38-year-old man with no significant medical history presented with a 1.5 year history of asymptomatic yellow-brown papules and plaques on the face, neck, and forearms. Lesions were slowly increasing in number, nonpruritic, and atrophic. Differential diagnosis included xanthomas and histiocytic etiologies. Shave biopsy revealed non-caseating granulomas composed of epithelioid histiocytes with more foamy cytoplasm than typically seen in traditional sarcoid histiocytes, multinucleated giant cells, and asteroid bodies. This subtle cytoplasmic vacuolization may have contributed to the lesions’ yellow hue. There were no cholesterol clefts. 

Labs revealed elevated IL-2 receptor, calcium, calcitriol, and alkaline phosphatase; chest x-ray was normal. Lipid panel was unremarkable. In retrospect, the patient endorsed intermittent palpitations, atypical chest pain, and mild dyspnea, all resolving after starting hydroxychloroquine. Given the risk of potentially fatal silent cardiac sarcoidosis, he was referred to pulmonology, cardiology, and ophthalmology for evaluation. 

Xanthoma-like cutaneous sarcoidosis is an uncommon morphology. These lesions mimic xanthomas, necrobiotic xanthogranuloma, or histiocytic disorders, but the absence of lipid abnormalities and overt xanthomatous histiocytes excludes true metabolic lesions. Non-caseating granulomas with multinucleated giant cells and asteroid bodies, while not pathognomonic, are highly suggestive in the proper clinical context. This case highlights the importance of histopathologic confirmation in persistent papular eruptions and the need for systemic evaluation to detect subclinical organ involvement.