Correspondence

A 33‐year‐old woman presented with several subcutaneous nodules of 1 month duration partially coalescing into plaques on her forearms. She had been suffering from Cushing's disease due to a pituitary microadenoma, which had been diagnosed and treated by trans‐sphenoidal surgery 3 months previously. She was taking cortisone acetate, 37.5 mg orally each day, for post‐hypophysectomy hypocorticism. The subcutaneous lesions varied in size from 1 to 6 cm and were flesh‐colored, movable at palpation, and painless. Light microscopy of both nodular and plaque‐like lesions revealed multiple subcutaneous aggregations of histiocytes with several multinucleated giant cells and lymphocytes ( Fig. 1). Special stains for acid‐fast bacilli and fungi and examination under polarized light gave negative results. 1Nodular aggregations of mononuclear histiocytes with giant cells in the hypodermis (hematoxylin and eosin, ×100) Chest X‐rays revealed a moderate bilateral hilar gland enlargement, but the radioactive gallium‐67 uptake was normal. Pulmonary function tests were also normal, except for the single‐breath carbon monoxide test (4.54 mmol/min/kPa: 68% of predicted). Serum angiotensin‐converting enzyme (ACE) was raised to 77 U/I (normal; 8–52). The intradermal response to purified protein derivative was found to be suppressed. To confirm the diagnosis of sarcoidosis, the patient underwent a broncho‐alveolar lavage (BAL). The immunophenotyping analysis of T‐lymphocyte subsets in the BAL was suggestive of sarcoidosis, showing a marked increase of CD4 positive cells (71.2%), CD8 positive cells being normal (24.6%). Considering that the only systemic manifestation of sarcoidosis was a moderate bilateral hilar enlargement, the cortisone acetate dosage was kept unchanged, and only a regular follow‐up was recommended.