Sarcoidosis

A 4-year-old boy presented with a history of recurrent fever for 4 months with reduced appetite, easy fatiguability, and occasional joint pains. There were no symptoms of weight loss, systemic symptoms, or history of contact with tuberculosis. His general physical examination was normal except for mild pallor. His systemic examination, including musculoskeletal system examination, was also normal. A complete blood count revealed a hemoglobin level of 9.2 g/dL with normal total and differential leucocyte counts. The C-reactive protein (CRP) was normal, and the erythrocyte sedimentation rate (ESR) was elevated. Peripheral blood smear showed no atypical cells or hemoparasites. Urine analysis, liver and kidney function tests, chest radiography, and abdominal ultrasound were normal. The tuberculin skin test was negative. Serological evaluations for autoantibodies (antinuclear antibody, anti-ds-DNA) were all negative. Slit lamp ophthalmic examination revealed subacute granulomatous uveitis. Repeat clinical examination revealed two well-defined erythematous brown-colored, slightly raised plaques on both the shins. The lesion was biopsied, and histopathological examination of the deep dermis revealed naked, non-caseating epithelioid cell granulomas, possibly sarcoidosis. Serum and urine calcium levels were normal, but serum angiotensin-converting enzyme (ACE) level was raised (78 U/L; normal range 8–65 U/L). Since all other infective workup was negative, a diagnosis of sarcoidosis was made. The child was treated with corticosteroids and methotrexate and was improving.