Herpes Zoster in a 10 year-old

The patient is an otherwise healthy ten year-old boy with a two day history of grouped zosteriform vesicles on the left arm, anterior shoulder and upper back.  He has mild discomfort.  No known illnesses and on no medication.  He had two immunizations for varicella at the approopriate ages.

Observation:  All of the grouped vesicles appeared to be of uniform size.

Lab:  A Tzanck smear was positive for multinucleated giant cells.

Diagnosis:  Herpes zoster roughly C3 - 6.

Herpes zoster in children is unusual but not all that rare.  There are a few cases of HZ after vaccination for varicella.  As he felt well, and as the effect of specific antiviral therapy is not striking; after discussion with his mother it was elected to simply follow.  In out opinion, in healthy children and young adults the course of HZ is usually relatively mild and almost never followed by post-herpetic neuralgia.  Immunity seems to wear off over time and it appears that this attenuated vaccine is capable of causing H.Z.  The other possibility is that this is zosteriform simplex.  We did not culture for that. 
While researching this case, we looked up "zosteriform simplex."  An observation (ref 4) indicates that in these patients the vesicles are of uniform size (as we see here).  This would tilt us towards a diagnosis of Zosteriform Herpes Simplex here, and not of vaccine failure.  Should this child get a recurrence, that would clinch the diagnosis.

Reference:
1. Herpes zoster in children.

Peterson N, Goodman S, Peterson M. Cutis. 2016 Aug;98(2):94-5.

Abstract: Herpes zoster (HZ) in immunocompetent children is quite uncommon. Initial exposure to the varicella-zoster virus (VZV) may be from a wild-type or vaccine-related strain. Either strain may cause a latent infection and subsequent eruption of HZ. We present a case of HZ in a 15-month-old boy after receiving the varicella vaccination at 12 months of age. A review of the literature regarding the incidence, clinical characteristics, and diagnosis of HZ in children also is provided.

 

2. Herpes zoster and zosteriform herpes simplex virus infections in immunocompetent adults.

Kalman CM, Laskin OL. Am J Med. 1986 Nov;81(5):775-8.

Abstract: Among 111 immunocompetent patients referred to a general hospital setting with the clinical diagnosis of herpes zoster, viral cultures were obtained from 47 patients. Six of these patients (13 percent) had herpes simplex virus isolated, with four of the six infections involving the facial distribution, and the other two involving the T4 (breast) distribution. Excluding those in whom herpes simplex virus was isolated, the mean age (+/- SD) of the remaining 105 patients was 50 +/- 19 years. Thirty-two percent of the patients were at least 65 years old; however, 39 percent were younger than 40 years of age. Thus, herpes zoster frequently occurs in young, immunocompetent adults. Also, since zosteriform rashes may be caused by herpes simplex virus, viral cultures of lesions are useful to differentiate infections caused by herpes simplex virus from those due to varicella-zoster virus. The need to distinguish between these two viruses may be important with the advent of antiviral drugs and for use of the proper epidemiologic isolation procedures.

3. Varicella Vaccine (Wiki)
Vaccines are less effective among high-risk patients, as well as being more dangerous because they contain attenuated live virus. In a study performed on children with an impaired immune system, 30% had lost the antibody after five years, and 8% had already caught wild chickenpox in that five-year period.

4. Zosteriform herpes simplex and herpes zoster: A clinical clue

Sanath Aithal, Sheela Kuruvila, and Satyaki Ganguly. Indian Dermatol Online J. 2013 Oct-Dec; 4(4): 369.  Free Full Text.

Excerpt: An important clinical observation by many authors that the vesicles of herpes simplex are uniform in size in contrast to the vesicles seen in herpes zoster, which vary in size. In other words, vesicles of herpes simplex are uniform within a cluster.

Vascular Lesion in a Six Year-Old

The patient is a 6-year-old boy who was seen for evaluation of a lesion on his right knee that has been present since infancy.  When he is active it swells up a bit and is uncomfortable, if not painful. He is in otherwise good health and his identical twin has no such lesion.  The child has seen by his family practitioner and two or three pediatricians.  He has had ultrasounds and x-rays, but none were diagnostic.  

O/E:  The examination shows a subtle dusky area on the right knee.  There are some vascular lesions within the area that are a millimeter in diameter or less.   Dermatoscopy more clearly defines them.

Clinical Photos:

PLAN:  A 4 mm punch biopsy was taken for diagnostic purposes. He may need to be referred to a center where they deal with vascular anomalies.   

Pathology:
Lymphatic malformation consistent with, in the appropriate clinical setting, lymphangioma.
The specimen exhibits compact hyperkeratosis, papillomatous epidermal hyperplasia, focal acanthosis, a sparse superficial perivascular lymphocytic infiltrate, and multiple dilated, irregular thin-walled vessels lined by a single layer of bland endothelial cells in the papillary dermis.

IMPRESSION:  Vascular anomaly: Lymphangioma    

FitBit Dermatitis

The patient is a 54-year-old woman with a history of severe  atopic dermatitis.  She was seen today for evaluation of a dermatitis on the left wrist that began under her Fitbit Alta.  She thought that it might be an infection so she started applying Neosporin and within a day, it was much worse. 
During the intervierw, the patient said, with feeling, "I love my FitBit."

O/E:  The examination shows a localized area of dermatitis with crusting on the left wrist.  It is quite inflamed.

Images:

IMPRESSION:  Possible irritant versus allergic reaction to Fitbit followed by application of Neosporin with what appears to be an allergic contact dermatitis.           

PLAN:  She will need to stop the Fitbit for the time being.  Fluocinonide 0.05% ointment twice a day to area.  Wet compresses.  Return as necessary.

References:

Initially, "Fitbit recalled the trackers and blamed rashes on allergic reactions to the nickel and glue in the wristband. However, scientists at the Consumer Product Safety Commission were testing a different theory.

They found that sweat in the charger caused a chemical reaction that produced a toxic compound, saying: "This scenario is supported by one consumer stating their injury occurred after charging... and a skin burn the shape of the charging port in another incident."
See: Possible cause of Fitbit rashes uncovered.

This it is unclear at this point.  Nickel allergy is easy to test for, however.

 

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A Nail Struggle

Isolated Nail Dystrophy - Left Thumb

My Nail 2 March 2015

March 2015
"I’m not sure exactly how I damaged my nail, but it happened in May 2014 when I was working outdoors clearing brush. Either I banged it really hard or dropped something on it. It never really hurt, but it quickly became unsightly, with lots of bruising, mottling from black to deep mahogany to orange to yellow. The nail developed a significant ridge until October 2014, when it came off in one piece.

Underneath was what you saw pictured above, a partial nail that is quite horny and yellow on the lower right and not tightly attached; it seems to grow outward rather than lie flat. I had an acrylic nail put on when I had to be very public for a couple of weeks; otherwise I’ve mainly kept a bandaid over it so that I won’t keep hitting it and also because it’s so ugly."

Note:  A KOH scraping was negative and fungal culture was taken. 

Six month Follow-up.

The culture grew out (Scopulariopsis), a saprophytic fungus and the patient has been using topical Tea Tree oil.  There has been marked improvement.  We recommend continued conservative management.  The nail did not continue to do well and the patient took terbinafine 250 mg a day for 3 month (no benefit).

January 2017
The patient's nail now shows signs of onycholysis.  It now has a green color indicative of "chloronychia." This is probably psudomonas.  She has had a nail dystrophy now for ~ two years. I think probably best to treat for pseudomonas, but the patient is wondering if her nail should be removed.

February 24, 2017

Dermatoscopy of Nail Fragment

photomic of Scopularopsis (from WWW)

2.24.2017
The nail was pared back.
The patient will apply 40% urea cream to the nail plate and bed and tape the surrounding area.
She will use topical gentamycin and a topical antifungal.

Pathology: PAS Stains from Nail (2.24.17) Showing fungal elements.

4.5.2017 
This is the appearance six weeks after nail trimmed back which was followed up by topical gentamycin for pseudomonas, Jublia, and one pulse of itraconazole (400 mg daily for seven days)  Two more pulses are planned.

5.18.2017

6.26.17

June 26, 2017 is after three montly pulses of itraconazole (400 mg b.i.d. x 1 week/month) and daily topical efinaconazole (Jublia).  We plan to keep up with the latter for another couple of months.  This is the best the patient has looked in three years.  She still may have a bit more to go.

Questions:
What would be the best topical antifungal available in the U.S. for this patient?
Is there a role for a different systemic antifungal, such as itraconazole? (Terbinafine was not successful)
What role does the taping play?

Reference:

1. Onychomycosis Caused by Scopulariopsis brevicaulis: Report of Two Cases

Myung Hoon Lee, M.D., et. al. Ann Dermatol. 2012 May; 24(2): 209–213.  Free Full Text.

2. Anchor Taping Method per Dr. Hiroko Arai.

3. Onychomycosis caused by Scopulariopsis brevicaulis: report of two cases.

Lee MH1, Hwang SM, Suh MK, Ha GY, Kim H, Park JY.  PMC Full Text

Ann Dermatol. 2012 May;24(2):209-13.

Abstract: Onychomycosis is usually caused by dermatophytes, but some nondermatophytic molds and yeasts are also associated with invasion of nails. Scopulariopsis brevicaulis is a nondermatophytic mold found in soil as a saprophyte. We report two cases of onychomycosis caused by S. brevicaulis in a 48-year-old male and a 79-year-old female. The two patients presented with a typical distal and lateral subungual onychomycosis. Direct microscopic examination of the potassium hydroxide preparation revealed fungal elements. From toenail lesions of the patients, brown colonies with powdery surface, which are a characteristic of S. brevicaulis, were cultured on two Sabouraud's dextrose agar plates. Three cultures taken from nail plates within a 2-week interval yielded similar findings. Numerous branched conidiophores with chains of rough walled, lemon-shaped conidia were observed in slide culture by light microscopy and scanning electron microscopy. The nucleotide sequences of the internal transcribed spacer for the two clinical isolates were identical to that of S. brevicaulis strain WM 04.498. To date, a total of 13 cases of S. brevicaulis onychomycosis including the two present cases have been reported in Korea. Mean age of the patients was 46.1 years, with a higher prevalence in males (69.2%). Toenail involvement was observed in all cases including a case involving both fingernail and toenail. The most frequent clinical presentation was distal and lateral subungual onychomycosis in 12 cases, while one case was proximal subungual onychomycosis.

Acneiform Drug Reaction

The patient is a 32 yo student from the Central African Republic. On coming to the US he was discovered to have "latent TB" and offered isoniazid,  He elected to take this and started it in September 2016.  Around a month later, he developed deep-seated papules and pustures on his back, chest, neck and to a lesser extent face.  Treatment with a cephalosporin and Bacrim were not successful. He has also had an undiagnosed eye problem during the same period of time.

O/E There are cystic and somewhat purulent lesions in the above-mentioned areas.  This is most pronounced on the chest.

Dx:  Acneiform eruption secondary to INH.

Plan:  1. A biopsy will be done to confirm the clinical impression. 

2. Will need to get advice on whether to treat.

3. He seems to want prophylaxis for TB. Will find out about alternatives.
Does anyone have experience treating this type of acne?

Toddler with Black Nevus

This 18 month by was seen for a pigmented lesion of 2 - 3 months duration.  It has growm over this

O/E:  Light complected Caucasian with 6 mm in diameter black papule right anterior thigh.  The dermatoscopic appearance shows a somewhat starburst appearance at the periphery.

Photomicrographs (courtesy of Deon Wolpowitz, Boston University Skin Path)

Diagnosis:  Clinically and dermatoscopically and pathologically, this is a Reed Nevus.

Plan: The lesion has been excised with modest margins..

Reference:

Dermatol Pract Concept. 2016 Apr 30;6(2):37-41. (Full Text)

Spitz/Reed nevi: a review of clinical-dermatoscopic and histological correlation.

Pedrosa AF et. al.

Abstract

BACKGROUND: Spitz/Reed nevi are melanocytic lesions that may mimic melanoma at clinical, dermatoscopic and histopathological levels. Management strategies of these lesions remain controversial.

OBJECTIVES:

We aim a correlation among clinical-dermatoscopic and histological features of a series of Spitz/Reed nevi diagnosed during 7 years at the Department of Dermatology.

METHODS: Clinical, dermatoscopic and histological features of Spitz/Reed nevi diagnosed at our tertiary hospital from 2008 to 2014 were reviewed in order to seek correlation.

RESULTS: All described dermatoscopic patterns for Spitz/Reed nevi were found among the 47 enrolled patients; starburst and atypical/multicomponent patterns prevailed (57.4%). Reticular pattern predominated among children younger than 12 years, whereas homogeneous pattern was more frequent in patients older than 12 years, although these differences were not statistically significant (P=0.785). Among histological atypical lesions, all dermatoscopic patterns were represented, but the atypical/multicomponent predominated (56.3%). Two out of 11 dermatoscopically atypical lesions did not show histopathological counterpart.

CONCLUSIONS: The excision of Spitz/Reed nevi in adults is supported, given the inability to accurately predict those with histopathological atypia, based on clinical and dermatoscopic features, which may raise concern about malignancy.

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Raynaud's with Digital Ulcerations in a Smoker

The patient is a 63-year-old waitress who presents for evaluation of painful fingertip ulcerations that have been present for ten months. She has been seen by a number of physicians including the Wound Care Center. Nothing has helped.  She has had Raynaud’s Disease for 7 – 8 years.  She has been a heavy smoker for decades and has cut down from two packs per day to 1/2 ppd a month or so ago.

Medications: Nifedipine for her fingertip ulcers without any help.  She’s also taking lisinopril and carvedilol for hypertension. Her ulcerations were treated with Bactrim and oral clindamycin without effect.

The Examination shows a pleasant articulate woman. She has markedly erythematous hands that appear somewhat puffy. There are two purulent subungual digital ulcers.

Clinical Photos: (1/16/17)
The erythema was quite dramatic.  I should have taken my associate's hand next to the patient's hand for comparison.

IMPRESSION:

Raynaud’s disease with ulcerations. Should we consider progression to scleroderma?  Could this be Buerger’s Diasease?. Her history of smoking may be significant.

Lab: ANA 1:2560 Centromere, RF 25, C4 low 94, C3, nl.  Low titer antibeta 2GP Igm. Negative ACA and LAC, negative ENA, dsDNA, CCP
Xray: resorption of distal L small finger

Note:
Raynaud's occurs in two main types:

• Primary Raynaud's is the most common form of the disorder and is not connected to an underlying disease or related medical problem. It is also called Raynaud’s phenomenon.
• Secondary Raynaud's is also called Raynaud's phenomenon. This form is caused by an underlying, or related, problem. Secondary Raynaud's is less common than the primary form, but it tends to be a more serious disorder. Symptoms of secondary Raynaud's often first appear at later ages — around 40 — while people with the primary form often see symptoms earlier.

PLAN: I had a long discussion with the patient. We talked about the need to stop smoking and she promised to do so. A prescription for Bactroban ointment was given and she will be seen back in one week.

With her permission, she is being presented here on VGRD.

Follow-up:
The digital ulceration of the left fifth finger has progressed to distal reabsorption with bone protrusion.  X-rays and orthopedic consultation is pending.

Comments of Richard Sontheimer, M.D.
These are extended and useful remarks that begin with: "This patient’s digital ulceration and the puffiness of her fingers together argue strongly in favor of systemic sclerosis. The fingertip ulceration in your patient would be highly atypical for isolated benign Raynaud's disease.  And, Buerger's disease would not typically produce the sausage-like digital swelling,"  Please read the entire link as it is very helpful.
Also see Reference # 3 below.

Reference:

1. Ann Dermatol Venereol. 2013 Aug-Sep;140(8-9):549-54. doi: 10.1016/j.annder.2013.02.010. Epub 2013 Apr 11.
[Minimal work-up for Raynaud syndrome: a consensus report. Microcirculation working group of the Société française de médecine vasculaire]. [in French]

Pistorius MA1, Carpentier PH; le groupe de travail « Microcirculation » de la Société française de médecine vasculaire.

Abstract: About ten to fifteen percent of the French population suffer from Raynaud's phenomenon. Most of the time, it is considered as primary Raynaud's phenomenon, without underlying disease. The aim of this expert consensus from the "microcirculation group" for the French Society of Vascular Medicine and the French Society for Microcirculation, was to define clinical guidelines in patients consulting for Raynaud's phenomenon. The recommended minimal screening includes clinical examination, nailfold capillaroscopy and antinuclear antibodies. In particular, the aim of this screening is to identify patients with a significant risk for scleroderma, who would need a careful follow up.
  

2. A portable dermatoscope for easy, rapid examination of periungual nailfold capillary changes in patients with systemic sclerosis.
Muroi E, et. al. Rheumatol Int. 2011 Dec;31(12):1601-6. doi: 10.1007/s00296-010-1532-0. Epub 2010 May 27.

Abstract: excerpt “The presence of two or more enlarged capillaries in one or more fingers showed 83.1% sensitivity and 100% specificity for SSc. Among patients with SSc with anti-topoisomerase I antibody, the disease duration correlated negatively with the dermatoscopic number of enlarged capillaries and hemorrhages. Dermatoscope allows the easy and rapid identification of capillary nailfold morphological changes in SSc and should be routinely used for diagnosing SSc.”
 

3. Proximal nailfold microhemorrhage events are manifested as distal cuticular (eponychial) hemosiderin-containing deposits (CEHD) (syn. Maricq sign) and can aid in the diagnosis of dermatomyositis and systemic sclerosis.
McBride JD, Sontheimer RD.  Dermatol Online J. 2016 Feb 17;22  Free Full Text Online

CONCLUSIONS AND RELEVANCE:

Cuticular (eponychial) hemosoderin-containing deposits (CEHD) are in fact hemosiderin-containing deposits that can reflect the active inflammatory phase of microvascular injury occuring in autoimmune disorders such as DM and SSc. CEHD can be visualized and documented at the bedside with tools commonly available to any dermatologist (portable dermatoscope and compact digital camera).

Neonatal Acne

Presented by Dr. Henry Foong, Ipoh Malaysia

21 day old boy

normal full term delivery

breast feeding

1 week history, initially forehead then spread too cheeks and nose area

mother is healthy and asymptomatic.

O/E: symmetrical/bilateral vesicles/ pustules/ papules/comedone on affected areas

 Dx: neonatal acne/ cephalic pustulosis

A benign condition.  i think it revolves with our treatment

Treatment:  reassurance!!

Comment by a pediatric dermatology colleague: "Neonatal acne is a common newborn eruption, and it can be seen in about 20% of healthy babies. The scalp, face, neck and back and chest are commonly affected, and open comedones are usually absent as this finding would make one consider infantile acne. The lesions are usually not present at birth, but typically appear within the first 2-4 weeks of life, and generally improve by about 4-6 months of age. This condition is self-limited, however, one can consider topical antifungal or low potency topical corticosteroid if the parents seek for medical treatment. Usually reassurance would comfort the parents." [The role of P. ovale is considered]

Reference:

Neonatal Malassezia furfur pustulosis.

Rapelanoro R, et. al.

Arch Dermatol. 1996 Feb;132(2):190-3.

Abstract

BACKGROUND:

Papulopustular eruptions of the face in neonates are frequently referred to as neonatal acne or sebaceous miliaria. Our findings suggest that there is an association between this type of eruption and Malassezia furfur infection.

OBSERVATIONS:

Direct examination of pustule smears showed M furfur yeasts in eight of 13 cases involving neonates with erythema and papulopustules of the face, neck, and scalp (mean age at onset, 22 days [range, 7 to 30 days]). The pustules were predominantly neutrophilic. Treatment with 2% ketoconazole cream applied topically twice daily was effective in 1 week.

CONCLUSION:

Malassezia furfur is frequently associated with a common nonfollicular pustulosis of the newborn, probably improperly termed neonatal acne.

Aquagenic Wrinkling of the Palms

The patient is a 19 yo woman who presents with a four month history of a peculiar eruption of her palms after showering.  She spends 15 - 20 minutes in the shower.  The process resolves within a 1/2 hour.  It is mildly pruritic.

O/E:  The eruption is comprised of 1 - 2 mm in diameter white papules, discrete and confluent, on the palms.  We demonstrated these lesions in the office and they cleared within 10 minutes.  Here feet are unaffected, by history.

Clinical Photos provided by patient: (directly after shower, and when returned to baseline.

 Diagnosis:  Aquagenic Wrinkling of the Palms

Question:  The literature states that this is more common in people with cystic fibrosis and CF carriers.  This patient has no history to suggest CF.  Should genetic testing be offerred? 

Reference: There are many case reports; but the Dermnet site is a great overview. 

CF Genetic Testing. (from Cystic Fibrosis Foundation web site)
In the United States, the number of people who carry a CF gene mutation is about:

• 1 in 29 Caucasian-Americans
• 1 in 46 Hispanic-Americans
• 1 in 65 African-Americans
• 1 in 90 Asian-Americans

Pretty, Ugly Thing

This 64 yo light-complected carpenter noticed a few rough spots on his chest. Since he vacations in Mexico two to three times a years, he is worried re: skin cancer.

A skin exam showed a 4 mm nodular BCC on his chest and a few hypertrophic AKs on the chest.  An incidental finding (that he was unaware of) was a 6 mm in diameter irregularly pigmented papule on the right upper back.  The dermatoscopic image is ugly and worrisome.

He is scheduled for an excisional biopsy.

This case is very similar to that presented on VGRD last week.  Therefore, this patient probably has a SSM that is < 1 mm thick.  We will see.

New Pigmented Lesion

Thiss 56 year-old man was brought into the office by his wife who has noticed a new pigmentedlesion on his mid-back for around a year.  He did not see the point in coming in, but she made the appointment and came in with him.

The exam showed a 1.1 cm pigmented nodule with a play of color and irregular borders.  The dermatoscopic exam shows whitish areas, black areas, and pigment dots (among other things).

Clinically, I thought this was a superficially spreading melanoma.  I could not be 100% sure it was not a seborrheic keratosis.

An excisional biopsy was done.  Pathology will be added in a few days.
Pathology:  Superficial spreading melanoma, at greatest, 0.68 mm thick.
I will recommend a WLE.  Not further studies.

Note:  Often, a wife will make the appointment for her husband who is reluctant to see the physician.  This patient insisted on going to work as a pipe-fitter after the excision.  When a wife finds a lesion on her skin and asks her husband to take a look; he often says to her, "If your worried, see a doctor."

A Case for Diagnosis

History: The patient is an otherwise healthy 67 year-old writer with a three month history of an intensely pruritic papular and pustular dermatitis in an otherwise.  He’s been on Welbutrin, HCTZ and Lipitor for years.   Previously treatments with triamcinolone 0.1% ointment and prednisone for two weeks were not helpful. 

O/E:  There are hundreds of 2 – 3 mm erythematous papules on arms, legs, torso, scalp.  Face spared.  No lesions on hands, feet or genitalia.

Clinical Images:

Pathology:

Lab:  CBC, Chemistries normal.  Wound culure grew 2+ SAUR sensitive to everything.
The patient was treated with Keflex 250 mg qid for a week and Prednisone starting at 40 mg a day.  He cleared quickly, but when he stopped the prednisone after ~ 3 weeks, the eruption and pruritus recurred.  The new lesions are distinct erythematous papules mostly on the torso.  Background looks normal.

Thoughts:  Could this be "subacute prurigo" othewise known as Itchy Red Bump Disease?  I will have slides reviewed and offer another biopsy to the patient.

Cutaneous Sarcoidal Granulomas

thinking outside of the box

57 year-old woman with a one-year history of an eruption on arms and legs

This 57 y.o. woman first noticed asymptomatic, erythematous patches on arms and legs a year ago.  She is in otherwise good health and was taking Losartan/ HCTZ and Pravastatin for hypertension and cholesterol by mouth.  She lived in Texas for five years in the 1980s, but otherwise spent her entire life in Western Massachusetts.

In September 2016, biopsies obtained from the right arm and left leg showed sarcoidal granulomatous dermatitis.

Clinical:
Her skin lesions, mostly on the arms and legs, are few and scattered. They are erythematous, slightly scaly, ill-defined plaques with irregular borders.

Pathology:
Photomicrographs graphs and interpretations courtesy of Dr. Deon Wolpowitz
Boston University, Department of Dermatology
The specimen exhibits superficial and deep, nodular well-formed collections of epithelioid histiocytes and multinucleated giant cells forming granulomas with sparse to mild lymphocytic rims and a moderate superficial and mid perivascular lymphocytic infiltrate. The histologic differential diagnosis includes sarcoidosis, a foreign body reaction, and infectious etiologies including mycobacterial infections. Polariscopic examination is negative. Fite stain is negative for mycobacteria. PAS stain is negative for fungal organisms.

Lab:  CBC and chemistries were normal, as was her chest x-ray.

Discussion:  This woman has no risk factors for sarcoidosis, but did spend five years in a geographic setting where sarcoid is more commonly seen. The only thing we came up with was that she was using a cat litter with silica in it and there is one reference in the literature to that being associated with sarcoidosis.

References:

1. Cat litter is a possible trigger for sarcoidosis.

Drent M, Wijnen PA, Boots AW, Bast A. Eur Respir J. 2012 Jan;39(1):221-2.  Free Full Text.  This is the fascinating report of a single case of pulmonary  sarcoidosis that appeared to be causally related to silica containing kitty litter.

2. Mahony J, Helms SE, Brodell RT.  The sarcoidal granuloma: A unifying hypothesis for an enigmatic response. Clin Dermatol. 2014 Sep-Oct; 32(5):654-9

Abstract: Although the cause of sarcoidosis is unknown, there is growing support for the concept that sarcoidal granulomas result from a hypersensitivity reaction producing a nonspecific response to an extrinsic or intrinsic (autoimmune) antigen in genetically susceptible individuals. The immune milieu associated with these antigens, localized in a specific cutaneous area, produces a variant of Ruocco's "immunocompromised district." This may explain the predilection for sarcoidal granulomas in association with foreign bodies, tattoos, herpes zoster-affected dermatomes, and scars. Similar antigenic stimulation produces sarcoidal granulomas surrounding internal tumors. Finally, systemic sarcoidosis, as manifested by hilar adenopathy, may reflect the lymphatic spread of foreign antigens.