Exposure to Chromium May Cause Subcutaneous Sarcoidosis, Case Report Suggests

Exposure to chemical substances used in leather tanning may have been the cause of a rare case of subcutaneous (under-the-skin) sarcoidosis around a man’s left eye and mouth, a recent case report suggests.

The report, “Occupational exposure as a presumable cause of subcutaneous sarcoidosis in a tannery worker – case report and review of the literature,” was published in the journal Advances in Dermatology and Allergology.

Skin lesions are observed in about 25 percent of sarcoidosis patients and may be the first sign of the disease. Although the cause of the disease remains unclear, research indicates that occupational or environmental exposures may induce the formation of sarcoidal granulomas – small areas of inflammation, most frequently due to infections.

The study describes the case of 59-year-old man, a long-term tannery worker in Poland with proven chrome contact allergy, who was first referred to the dermatology department due to an under-the-skin infiltration and edema (swelling) in the left mouth area and upper eyelid. He also had significant narrowing of the left palpebral fissure – the area between open eyelids. These symptoms had started two years earlier.

Eye examination revealed no changes in the left eye, as well as normal visual acuity. Magnetic resonance imaging (MRI) of the orbits showed thickening and enhancement of the left upper eyelid and the sclera —  the white of the eye — but no mass lesions.

Biopsy further revealed inflammation and the presence of granulomas beneath the skin (dermal), consistent with sarcoidosis.

Subsequent laboratory tests revealed a slight elevation of different markers of inflammation. No signs of lung inflammation or lymph nodes enlargement – common symptoms in sarcoidosis – were detected, however.

Based on the clinical appearance and the diagnostic examinations, the clinicians made a diagnosis of subcutaneous sarcoidosis of the left periorbital area (around the eye). They prescribed treatment with the anti-inflammatory chloroquine 750 mg/day, which led to resolution of the infiltration and swelling within six months. The patient is now being followed regularly and treated with 500 mg/day chloroquine.

The team noted that subcutaneous sarcoidosis, as described in this patient, is rare and constitutes up to 12 percent of all skin manifestations of sarcoidosis; only 40 cases have been reported so far. Skin lesions are usually asymptomatic and consist of firm nodules under the skin.

Researchers also emphasized that isolated orbital disease is uncommon, and, as in the tannery worker patient, isolated.

“We hypothesize that subcutaneous sarcoidosis of the periorbital area diagnosed in our patient might be associated with working in a tannery where he was exposed to several occupational health risk factors,” the researchers wrote. Among relevant risk factors, the authors mentioned benzene-based dyes and formaldehyde, as well as chromium.

Exposure to chromium is known to increase the risk of skin inflammation, ulcers, and respiratory illnesses. It also may induce skin sarcoid granuloma in sensitized individuals.

“Our patient had a proven chrome allergy, and skin contact with the metal might have induced sarcoid reaction, especially as the patient had the habit of rubbing the left eye area with his fingers,” the team added.

“Since eye disease may be silent, a detailed examination of the eye is strongly recommended and sarcoidosis should be considered as the cause of abnormal eye findings,” they concluded.