A 74-year-old Japanese woman had asymptomatic plaques of 3 months' duration. She had had hepatitis C virus for about 5 years. No palpitations, syncope history or arrhythmias were detected. Her physical examination revealed 5mm, irregularly shaped plaques on her face (Figure 2A). She had never received interferon therapy. Her complete blood count, liver function tests and serum electrolytes were all normal. ACE, lysozyme and ANA levels were also normal. Histopathologically, naked epithelial cell granuloma with giant cells were observed in the upper dermis (Figure 2B). PET-CT images revealed mediastinal and hilar lymph node (LN) swelling and multiple middle and inferior myocardial wall uptakes (Figure 2C). Her cardiac ejection fraction rate was 67%, and Holter electrocardiography revealed premature ventricular contractions and right bundle branch block. She was treated with 30mg prednisolone, and a pacemaker was implanted by a cardiovascular physician.
The other 12 patients were also Japanese. Two were male, and ten were female. Their ages ranged from 32 to 93 years. Their average age was 63 (Table 1). Among the 12 patients, 10 (83%) were found to have internal involvement. Internal involvement was found in eight (89%) of nine patients by PET-CT and in two (67%) of three by Ga scintigraphy. Cardiac involvement was found in four (33%) of the twelve patients. In the 12 patients, we found a predominance of myocardial sarcoidosis with multiple facial plaque type cutaneous sarcoidosis (75%) without subjective symptoms. Autoimmune-associated disease was found in four patients, and viral hepatitis was detected in three. In our series, two patients (17%) had a history of Mycobacterium infections with positive tuberculin tests and QuantiFERON  TB2G tests (Cellestis, Chadstone, Australia). We used special stains, including, Bacille Calmette-Guerin stain, Grocott's methenamine silver stain, periodic acid-Schiff stain or Ziehl-Neelsen stain, to visualize acid-fast bacteria, but we could not find acid-fast bacteria, fungus or bacterial cutaneous infection in any of the biopsy samples. Cutaneous sarcoidosis was diagnosed on the basis of histopathology by the pathologist.