Foreign Body Granulomatous Reaction Presenting as Systemic Sarcoidosis: A Case Report with Energy-Dispersive Spectroscopy Analysis
Michael Singer,* Herb Srolovitz,
Robin Bullick, and André Dufresne
Background: Sarcoidosis is an
immune-mediated idiopathic disorder and is generally thought to
be a diagnosis of exclusion. Although researchers have looked at
viruses, mycobacteria, and certain chemicals as possible
triggers, the initiating antigen remains unidentified.
Observations: A 41-year-old black
male metal-worker previously diagnosed with systemic sarcoidosis
presented with a 6-month history or recurrent, sometimes tender,
skin nodules on the lower legs. Chest film, gallium scan, and
angiotensin-converting enzyme (ACE) level results supported a
diagnosis of systemic sarcoidosis. A biopsy of a lower extremity
skin nodule showed confluent non-necrotizing granulomas with
irregular birefringent particles in giant cells in a fibrous
tissue background suggestive of a silica nodule. Review of a
previous bronchila biopsy showed similar foreign body granulomas.
Energy-dispersive spectroscopy (EDS) analysis, clay (kaolinite),
chromium, and aluminum particles that were consistent with the
patient's occupational exposure.
Conclusion: ACE level and gallium
scan may not be specific for sarcoidosis. In certain occupational
settings, EDS analysis should be considered before a diagnosis of
sarcoidosis is made. This case may provide insight into the
etiology of certain presentations labelled as sarcoidosis.
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