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Introduction
Sarcoidosis is an inflammatory condition affecting multiple organs in the body, including the heart. Cardiac inflammation can disrupt normal cardiac function and lead to arrhythmias.
Case summary
We present a case of a 50-year-old female with no prior medical history who was diagnosed with myocardial sarcoidosis 6 years ago after presenting with symptomatic total block. Magnetic resonance imaging (MRI, Figure 1A) and myocardial biopsy confirmed the diagnosis. The patient was treated with anti-inflammatory medication and a permanent defibrillator was implanted. 18F-Fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) showed intense activity in the left ventricular walls following a carbohydrate-restricted diet (Figure 1B).
The patient was followed for several years, with sarcoidosis medication adjusted according to symptoms, laboratory, and imaging findings. In 2022, she was receiving treatment with infliximab infusion along with prednisolone at a dose of 5 mg/day and methotrexate at a dose of 7.5 mg/week. However, during the spring of that same year, she contracted a COVID-19 infection, and as a result, the infliximab infusion had to be discontinued. No cardiac symptoms were reported, but in late summer 2022, she noticed subcutaneous lumps in her extremities. Ultrasound was performed (Figure 2) and further MRI recommended.
In autumn 2022, an 18F-FDG-PET study prior to her cardiac control showed mild FDG activity in the heart, but active mediastinal lymph nodes (Figure 3A). Multiple 18F-FDG uptakes were also detected with corresponding hyperdense subcutaneous nodules on cardiac tomography (Figure 3B). These uptakes were identified as sarcoidosis and were likely the cause of the patient’s subcutaneous lumps. Prednisolone dosing was increased to 20 mg/day and decreased gradually, leading to the disappearance of the subcutaneous lesions on MRI within 3 months.
Conclusion
The subcutaneous form of sarcoidosis (Darier-Roussy) is a rare entity that should be considered in patients with sarcoidosis and new subcutaneous lumps1. It is important to consider this specific entity in patients with sarcoidosis who present with new subcutaneous lumps.
Reference
Ando M, Miyazaki E, Hatano Y, Nishio S, Torigoe C, Yamasue M. Subcutaneous sarcoidosis: A clinical analysis of nine patients. Clin Rheumatol 2016;35:2277‐81.
Funding
Open access funding provided by University of Eastern Finland (UEF) including Kuopio University Hospital.
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Neither Sillanmäki nor Iso-Mustajärvi have any disclosures to make.
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Sillanmäki, S., Iso-Mustajärvi, S. 18F-FDG-PET of cardiac sarcoidosis with subcutaneous nodules. J. Nucl. Cardiol. 30, 2839–2840 (2023). https://doi.org/10.1007/s12350-023-03302-7
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DOI: https://doi.org/10.1007/s12350-023-03302-7