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Old 12-07-2011
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Skin Epithelioid cell granulomas on skin biopsy

A 54-year-old man of Scandinavian descent comes to the office for a persistent rash of 2 years’ duration. He has used multiple topical medications, including topical corticosteroids and topical immunomodulators, to no avail. His past medical history is significant for essential hypertension and gout, which are well controlled with oral medication. The family history is unremarkable. On physical examination, he is no acute distress and his vital signs are within normal limits. Multiple discrete lesions are present on the face, trunk, and proximal extremities, as shown in the photograph. A skin biopsy performed several months earlier showed well-formed epithelioid cell granulomas with scant lymphocytes and giant cells.

Which of the following tests is the most appropriate next step in management?

A. Blood glucose level
B. Dental Panorex
C. Erythrocyte sedimentation rate
D. Total body scintigraphy with gallium 67
E. Tuberculin skin test

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Old 12-07-2011
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is it tuberculin skin test.
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Old 12-07-2011
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E. Tuberculin skin test on the basis of skin biopsy?
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Old 12-08-2011
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E. Tuberculin skin test
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Old 12-08-2011
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D. Total body scintigraphy with gallium 67

It cant be TB at all .Look at the lesions!!!!
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Old 12-08-2011
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The correct answer is D. This patient has sarcoidosis, a multisystem disorder of unknown origin. It most commonly affects young adults, and has the highest prevalence in Scandinavians and African Americans. Histologically, it is characterized by a noncaseating epithelioid cell granuloma. It can involve any organ of the body; however, the sites of predilection are lungs, lymph nodes, skin, and eyes. Skin manifestations appear in about 20 to 35% of patients with systemic sarcoidosis, but cutaneous sarcoidosis can also occur without systemic disease. The extent of cutaneous lesions does not correlate with the extent of systemic disease. The criteria for establishing the diagnosis of sarcoidosis include: 1) a compatible clinical and/or radiologic picture; 2) histologic evidence of noncaseating granulomata; and 3) negative special stains and cultures for microorganisms. Scintigraphy with gallium 67 represents a specific, noninvasive diagnostic investigation for systemic involvement, but a definitive diagnosis for cutaneous sarcoidosis requires the demonstration of noncaseating granulomas in the lesional skin. Two common findings seen in sarcoidosis with gallium scintigraphy are the lambda and panda patterns. Lambda pattern is produced by uptake of right paratracheal and bilateral hilar lymph nodes. “Panda image” is produced by symmetric uptake by lacrimal and parotid glands.
Blood glucose levels (choice A) are not affected by sarcoidosis, and this patient has no personal or family history of diabetes. Therefore, this test is not indicated as the most appropriate next step.
A dental Panorex (choice B) is performed for suspected lesions involving the maxilla and mandible as well as teeth. Sarcoidosis does not affect bones, but is likely to affect the salivary glands and the parotid. These may show up as soft-tissue swelling on a dental Panorex, but the test is not specific or sensitive enough for the diagnosis of sarcoidosis.
Erythrocyte sedimentation rate (choice C) is not altered in sarcoidosis. Even if it were abnormal, this is only a nonspecific indicator of inflammation and would not aid in making the diagnosis.
A tuberculin skin test (choice E) is performed for suspected Mycobacterium tuberculosis infection. However, it may also be used to evaluate delayed-type immune reactions. Patients with sarcoidosis may be anergic, but this is not a specific diagnostic test.
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