Clinical Snapshot
The Tiger Man Sign in Systemic Sarcoidosis
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A 33-year-old man was admitted to the hospital for investigation of acute kidney injury (creatinine 2.35 mg/dL) with hypercalcemia (3.12 mmol/L). He reported a history of nodular lesions on the skin of his lower arms accompanied by bilateral swellings of his hands and feet with a feeling of tightness. The production and excretion of urine were unchanged. Laboratory tests showed increased levels of soluble interleukin-2 receptor, angiotensin-converting enzyme, and 1,25(OH)2 vitamin D3. 2-[18F]FDG-PET/CT demonstrated bipulmonary nodules with a perilymphatic distribution pattern accompanied by mediastinal and bihilar lymphadenopathy with elevated glucose metabolism. Furthermore, the muscles of the extremities showed lesions indicating myositis (the tiger man sign; Figure). Magnetic resonance imaging of the lower legs revealed correlating intramuscular edema. Histological examination demonstrated interstitial nephritis. Systemic sarcoidosis was diagnosed. Treatment with prednisolone (starting at 1 mg/kg) and azathioprine (2 mg/kg) restored the creatinine and calcium levels to normal within 2 weeks. The tiger man sign, first described in 2012, is considered a characteristic finding in sarcoidosis.
Dr. med. Nikolas Ruffer, Dr. med. Martin Krusche, III. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, n.ruffer@uke.de
Dr. med. Daniel Köhler, Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie und Nuklearmedizin, Universitätsklinikum Hamburg-Eppendorf
Conflict of interest statement: The authors declare that no conflict of interest exists.
Translated from the original German by David Roseveare.
Cite this as: Ruffer N, Köhler D, Krusche M: The tiger man sign in systemic sarcoidosis. Dtsch Arztebl Int 2023; 120: 777. DOI: 10.3238/arztebl.m2023.0130
