Systemic sarcoidosis first manifesting in a tattoo in the setting of immune checkpoint inhibition

Abstract

The use of immune checkpoint inhibitors is revolutionising the treatment of cancer. However, their unique toxicity profile is substantially different from what has been observed with traditional chemotherapy, resulting in a novel learning curve for medical oncologists. Early recognition of these toxicities can make a substantial impact in ameliorating these side effects in the oncological and medical-surgical fields. Here, we present a case of Lofgren syndrome sarcoidosis, which first manifested in a tattoo in a patient with metastatic urothelial cancer on therapy with anti-CTLA-4 (ipilimumab) and anti-PD1 (nivolumab).

Figure 1

Sarcoid reaction manifesting in a tattoo after immune checkpoint blockade. Thickened, hyperkeratotic papular lesions developed along the outer edges of the tattoo after the patient received ipilimumab and nivolumab combination immune checkpoint blockade therapy. Although the patient did not want the tattoo to be biopsied, histopathology of a similar nodular lesion on his left naris revealed sarcoid.

Figure 2

CT of hilar lymphadenopathy, which was initially believed to be tumour progression. After three doses of immunotherapy, restaging CT scans showed interval enlargement in the known tumour mass in the bed of kidney resection and new hilar lymphadenopathy. Immunotherapy was discontinued due to disease progression on CT scans, and he began chemotherapy with gemcitabine and cyclophosphamide. However, a hilar lymph node biopsy via bronchoscopy showed no evidence of cancer but was consistent with sarcoid.

Figure 3

Methylprednisolone treatment decreased sarcoid lymphadenopathy. Methylprednisolone sodium succinate administration resolved the skin lesions, arthralgias and tattoo changes of the patient's Lofgren's syndrome. Repeat CT revealed a decrease in mediastinal and hilar lymphadenopathy (yellow arrows), suggesting a clinical response of sarcoidosis to the steroids. However, the lymphadenopathy due to malignance (red arrow) persisted.