Diagnostic challenges in childhood sarcoidosis.

The aim of our clinical image was to emphasize the value of a careful skin examination in the diagnosis of early-onset sarcoidosis in children.

CASE PRESENTATION

A 2‐year‐old child had a one‐year history of polyarthritis and recurrent rash that was not objectified during consultations. The diagnosis of juvenile idiopathic arthritis was made. The patient was treated with nonsteroidal anti‐inflammatory drugs and methotrexate. He was hospitalized after 2 months because of severe arhralgia and functional impairment. On skin examination, he had flesh‐colored, non‐itchy, 4 mm papular lesions on the arms and forearms with micropapular lesions on the trunk giving a keratosis pilaris‐like appearance (Figure 1). The ophthalmologic examination showed anterior uveitis with Koeppe and Busacca nodules. The child did not have respiratory symptoms or lymphadenopathy. The chest X‐ray and blood tests were without abnormalities. A skin biopsy showed non‐necrotizing granulomatous inflammation of the dermis, confirming the diagnosis of sarcoidosis (Figure 2). The patient was treated with systemic corticosteroids with improvement in clinical signs.

FIGURE 1

Flesh‐colored non‐itchy, papular lesions on the arms and forearms (black arrows)

FIGURE 2

Dermal and subcutaneous non‐necrotizing granulomas (red arrows) composed of epithelioid histiocytes with sparse lymphocytic infiltrate (H&E × 100)

Sarcoidosis in children poses a diagnostic challenge, especially before the age of 5, given the absence of the classic signs of sarcoidosis. Older children usually present clinical symptoms similar to those of adults with pulmonary infiltration and lymphadenopathy.

However, sarcoidosis is characterized at an early age by the triad: uveitis, arthritis, and rash. The cutaneous manifestations are variable: discrete and confluent papules, eczematiform, ichthyosiform lesions, subcutaneous nodules, symmetrical maculopapular lesions, or erythroderma. The rash is characterized by exacerbations and remissions. It often precedes other signs and can be discrete and go unnoticed.

CONFLICT OF INTEREST

The authors declare that there are no conflicts of interest in this work.

AUTHOR CONTRIBUTIONS

All authors had access to the data and a role in writing this manuscript. The authors fulfill the ICMJE Criteria for Authorship and contributed equally. Dr Manaa Linda, is the guarantor of the content of the manuscript, included the data and analysis. Dr Youssef Monia contributed to interpretation of data and revision of the manuscript. Dr Chouchene Chokri contributed to data collection. Dr Ben abdejlil Nouha and Belhadjali hichem contributed to analysis and interpretation of data, revised it critically. Dr zili jamaleddine and Dr Chouchene Sleh contributed to final approval of the version of the manuscript to be submitted.

CONSENT

The patient' parents in this manuscript have given written informed consent to the publication of the case details of their child.