INTRODUCTION: Sarcoidosis in patients with HIV is rare, and the association is not well established(1,2). Deficiency of CD4 cells defines HIV, while CD4 lymphocyte accumulation is characteristic of sarcoidosis. The understanding of these diseases conceptually challenges their coexistence. We herein report an unusual presentation of sarcoidosis in a patient with HIV, skin lesions, and significant bone disease resembling blastomycosis. 

CASE PRESENTATION: A 46-year-old female with HIV presented to an outside facility with thigh pain, skin lesions, and weight loss. There, CT revealed extensive mediastinal adenopathy and destructive lesions in her left ischium, left femoral head, and lumbar spine. Biopsy of the vertebral lesions revealed nonspecific histiocytic inflammation. She was discharged with outpatient follow-up but presented to the current facility a month later with the same complaints. Physical exam revealed multiple papular, flesh-colored lesions over her face, and labs resulted in CD4 and CD8 counts of 116 and 173 cells/μL, respectively, and an undetectable viral load. Given her immunosuppression, clinical picture, and area of residence, Amphotericin B was initiated for presumed blastomycosis. Additional testing for infectious causes, including Blastomyces, Histoplasma, and Aspergillus, were negative. Skin biopsy revealed granulomatous dermatitis with negative stains for acid-fast bacilli, spirochetes, fungus, or malignancy. CT-guided biopsy of left ischial lesion was performed, but given the patient’s clinical improvement, she was discharged on itraconazole with follow-up with her PCP and infectious disease (ID). In ID clinic, her biopsy results were reviewed.

FINAL DIAGNOSIS: Histopathology confirmed the diagnosis of sarcoidosis.

OUTCOME/DISCUSSION: Oral corticosteroids were initiated, and after several weeks, the patient improved. Importantly, this case highlights the danger of anchoring bias with certain historical data, such as HIV status. Despite classic findings and demographical features, the patient’s diagnosis was delayed while other differentials were considered. The seemingly paradoxical coexistence of HIV and sarcoidosis is rare, but unlike the other <100 cases reported to date, the patient in the present case had a CD4 count of <200 cells/μL, suggesting the underlying pathophysiology of sarcoidosis exceeds the suspected role of CD4 lymphocytes(3). Recognizing the limitations imposed by incomplete understandings of diseases can help generate a more inclusive list of differential diagnoses.

References and Resources

1. Trevenzoli M, Cattelan AM, Marino F, Marchioro U, Cadrobbi P. Sarcoidosis and HIV infection: a case report and a review of the literature. Postgrad Med J. 2003;79(935):535-538. doi:10.1136/pmj.79.935.535
2. Morris DG, Jasmer RM, Huang L, Gotway MB, Nishimura S, King TE Jr. Sarcoidosis following HIV infection: evidence for CD4+ lymphocyte dependence. Chest. 2003;124(3):929-935. doi:10.1378/chest.124.3.929
3. Cabrera César E, Piñel Jiménez L, Gallego E. Human immunodeficiency virus and sarcoidosis, a rare association. Med Clín (English Edition). 2022; 158(8):387-388. doi: 10.1016/j.medcle.2022.03.004.