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Unusual and memorable

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A 40 year old black women presented with pronounced soft tissue swelling of several fingers and toes, with tenderness and restriction of involved interphalangeal joints. A few patches of indurated depigmented skin were also noted. Radiographs revealed gross soft tissue swelling with deforming erosion and resorption of phalanges (figure).  Osseous involvement in chronic sarcoidosis occurs in about 5% of all patients. The most characteristic clinical picture is dactylitis resulting from granulomatous cyst formation in the phalanges where it may be the presenting feature of the disease particularly in black patients.1 Numerous radiographic features have been described including expanded phalanges with thin cortical bone and cyst-like spaces, round or oval punched out areas, and fine lattice-like configuration. Periostial reaction is rare. In severe cases, as in this patient, affected phalanges may be fragmented and resorbed with “telescoping” of the digit. Severe soft tissue swelling may result from granulomatous change in the tendon sheath and joint synovium adjacent to affected bones. Joint destruction and collapse may follow local extension of osseous disease.

Acknowledgments

Contributors:gary d wright, michael doherty. City Hospital, Nottingham, NG5 1PB, United Kingdom.

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