A 55-year-old woman presented with prominence of the nasal bones and difficulty in wearing eyeglasses for 3 months. Eighteen months earlier, she had presented to the dermatology clinic with skin lesions on extremities in a different hospital. Two punch biopsies from skin lesions were performed, and results of the histopathologic examination revealed noncaseating granulomatous inflammatory reaction. She had multiple cervical lymph nodes on the left side, with the largest being 16 x 8 mm. An excisional cervical lymph node biopsy was taken in the same hospital, and results of a histopathologic examination revealed caseating granulomatous inflammatory reaction. Results of a tuberculin skin test was also reported to be positive (10 mm) at that time. It was ascertained that the patient had been vaccinated. Unfortunately, no microbiologic analysis of the excised lymph node had been performed. Results of a sputum sample were negative for acid-fast bacilli. Based on the histopathologic finding of caseating granulomas, she was diagnosed as having tuberculosis of the skin and cervical lymph nodes, and received antituberculosis treatment (rifampicin 600 mg, isoniazid 300 mg, pyrazinamide 1500 mg, and ethambutol 1000 mg per day for 2 months, followed by 10 months of therapy with rifampicin 600 mg and isoniazid 300 mg per day). Cervical lymph nodes resolved, but no remission of skin lesions was reported by the patient, despite 1 year of therapy.
Results of a physical examination revealed diffuse nontender swelling over the nasal bones, which caused disfigurement of the bony nasal dorsum. There were no skin changes over the mass (Fig. 1). The nasal cavity and septum were normal except for mild crusting on the left inferior turbinate mucosa. There were no palpable lymph nodes in the neck, but there was a scar at the previous lymph node biopsy site. Results of the remainder of the head and neck examination were normal. Ultrasonography of the neck was also normal. There were multiple papular skin lesions on the upper and lower extremities (Fig. 2). Paranasal sinus computed tomography (CT) showed destruction of the nasal bones, with soft-tissue increase (Fig. 3). Because of her history, the patient was initially suspected to have tuberculosis that was affecting the nasal bones; however, skin lesions unresponsive to antituberculosis therapy and histopathologic demonstration of noncaseating granuloma in previous skin biopsy specimens raised the question about the former diagnosis of "skin tuberculosis." We reevaluated the previous data of the patient. We obtained the pathologic slides of the excised cervical lymph node and stained for acid-fast bacilli; the results of staining were negative. Further workup was carried out for the differential diagnosis of sarcoidosis which is the major cause of noncaseating granuloma. A chest radiograph indicated bilateral hilar adenopathy, which was then confirmed by a CT of the chest. There also were parenchymal nodular lesions on a CT of the chest. She had no pulmonary symptoms. Pulmonary function test results also were within normal limits.
The patient was admitted with a presumptive diagnosis of sarcoidosis versus tuberculosis, and incisional biopsy was done transnasally through and intercartilaginous incision with the patient under general anesthesia. Histologic examination results showed noncaseating epithelioid cell granulomas. Tissue samples also were provided for microbiologic assessment. Results of staining for fungi and acid-fast bacilli were negative. Results of a polymerase chain reaction test and culture for mycobacterium also were negative. Further workup for sarcoidosis revealed no ophthalmologic, renal, or cardiac involvement. Laboratory test results showed no specific evidence of any other disease. Serum and urine calcium and angiotensin-converting enzyme levels were normal. The patient was diagnosed with sarcoidosis and was started on prednisolone (40 mg/day) and hydroxychloroquine (400 mg/day). The therapy resulted in dramatic improvement of nasal bone, pulmonary, and skin lesions within 2 weeks (Fig. 4).