Post herpes-zoster scar sarcoidosis with pulmonary involvement
The present case report is about a 50-year-old man who presented with multiple, mildly tender skin colored lesions over left upper back of 18 months duration. Patient had a history of eruption of painful, grouped blisters in this region 2 years before, that resolved leaving behind scars. At 6 months later, patient noticed skin colored raised lesions appearing over these scars that gradually increased in extent. He also complained of low grade fever and progressive breathlessness on routine work for last 6 months. There was no history of hemoptysis. Cutaneous examination revealed multiple irregular, grouped skin colored papules and plaques of 3-10 mm in size arranged in a zosteriform pattern along right thoracic (T1) segment []. There was no evidence of excessive scarring or keloid formation at the site of previous healed injuries elsewhere in the body. Systemic examination including chest examination did not reveal any significant finding. Hematological investigations including serum calcium were within the normal limits. The level of serum angiotensin-converting enzyme was 82 μg/L (normal range 8-47 μg/L). Ophthalmologic examination and electrocardiogram were normal. Mantoux test performed with 1 IU of PPD was negative after 48 h. Sputum for acid fast bacilli (AFB) was negative on 3 consecutive occasions. Chest radiography showed hilar prominence on the right side. Contrast enhanced computed tomography – chest revealed bilateral lung fields showing miliary nodules along with subpleural involvement with interlobular peribroncho-vascular thickening and interspersed areas of consolidation involving bilateral upper lobes, lingula and apical segment of right upper lobe. Areas of fibrosis in right upper lobe with emphysematous changes were seen along with bilateral hilar lymph nodes []. The findings were suggestive of pulmonary sarcoidosis. Ultrasound abdomen was normal.\nHistopathological examination of lesional biopsy on hematoxylin-eosin stained sections revealed multiple, non-caseating epithelioid granulomas with Langhan's giant cells, focal fibrinoid necrosis and occasional lymphocytes at the periphery in superficial and deep dermis consistent with the diagnosis of scar sarcoidosis []. The evidence of scar was evident in the form of haphazard thick collagen bundles in the dermis extending up to the subcutaneous tissue. Polarizing microscopy and special stains for AFB and fungus were negative. A diagnosis of scar sarcoidosis with pulmonary involvement was made. Patient was prescribed prednisolone 40 mg/day and clobetasol propionate (0.05%) cream to be applied twice a day over the lesions. At 4 weeks treatment led to decreased breathlessness and a 50% reduction in size of the lesions.