Weekly Case

Title : Case 655

Age / Sex : 57 / F


Chief complaint : palpable nontender masses in bilateral buttock and lower legs.


What is your diagnosis?

Two weeks later, you can see the final diagonosis with a brief discussion of this case (Please submit only one answer).


Courtesy : Hyun-joo Kim, Soonchunhyang University Seoul Hospital.


Diagnosis:

Subcutaneous sarcoidosis



Discussion


 


Findings:


There are multiple irregular shaped heterogeneous low echoic lesions in subcutaneous fat layer of both buttock and lower legs with surrounding hyperechoic swelling of surrounding subcutaneous fat layer tissues.


The lesions showed ill-defined isoattenuating lesions in bilateral buttock, subcutaneous fat layer on CT with slight enhancement.


  


Differential Diagnosis:


 Primary cutaneous follicular lymphoma.


 Panniculitis, such as erythema nodosum.


 


 Discussion:


 Subcutaneous sarcoidosis.



  • Less frequent form of cutaneous sarcoidosis.

  • Only in 1.4~6 % of patients with systemic sarcoidosis and isolated subcutaneous sarcoidosis is very rare.

  • Usually appears in the early stage of sarcoidosis à Useful for diagnosis of systemic sarcoidosis.

  • P/Ex: Painless multifocal firm soft tissue nodules. More frequent in upper extremity. Located on more than one anatomical site.

  • Image findings

    • CT

      • Nodular (well defined and homogeneous lesion with isoattenuation as the muscle) vs diffuse (ill-defined and heterogeneous with a honeycomb-like pattern) type



    • MRI

      • Nodular lesion: IsoSI with the muscle on T1WI and heterogenous high SI on T2 WI.

      • A mesh or stripe pattern of intermediate SI on both T1- and T2-WI.

      • Slight enhancement.



    • US findings (nonspecific)

      • Irregular hypoechoic lesions surrounded by hyperechoic zone with thickening of surrounding subcutaneous tissue.

      • Associated with hypervascularity in the lesion.






 


References:



  1. Tetsuya Shinozaki . Hideomi Watanabe. Jun Aoki et al. Imaging features of subcutaneous sarcoidosis. Skeletal radiology 1998;27:359-364.

  2. Chen HH, Chen YM, Lan HH, Lee CH, Chen DY. Sonographic appearance of subcutaneous sarcoidosis. J Ultrasound Med. 2009;28(6):813-6.

  3. Saori Tada, Tsuneo Watanabe, Chigusa Suzuki et al. Sonographic Findings of Subcutaneous Sarcoidosis in 3 Cases. J Ultrasound Med 2015; 34:1485–1488.


 



Correct Answer
Total applicants 29 Correct answers 17
Name Institution
윤유성 순천향대 부천병원, 전문의
이지현 삼성서울병원, 전문의
장민영 국민건강보험공단 일산병원, 전문의
김기욱 국군수도병원, 전문의
강지희 서울대학교병원, 전문의
여현정 전문의
한유비 병무청, 전문의
최형인 군의관, 전문의
전인환 전문의
이연옥 선한목자병원, 전문의
김동수 전공의
김성진 365병원, 전문의
김형민 전문의
권기언 명지병원, 전공의
이혜란 전문의
김지은 서울대학교병원, 전문의
김동언 국군양주병원, 전문의
Semi-Correct Answer
Total applicants 29 Semi-Correct answers 6
이진영 전문의
조영민 전문의
이규정 고대안암병원, 전문의
최현일 전공의
홍상협 군의관, 전문의
백승진 분당차병원, 전공의


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