Extrapulmonary Sarcoidosis Presenting as Bilateral Lower Limb Erythema Nodosum Triggered by Intradermal Fillers: A Case of Misdiagnosis As Soft-Tissue Infection

Localized inflammatory reactions in patients with past procedural history of intradermal injections can quickly drive the clinician's attention towards a diagnosis of soft-tissue infection in the context of symptoms such as fever, malaise, and local induration of the adipose panniculus. However, in patients with a long-term history of granulomatous events, a rheumatologic approach must be taken into consideration when the clinical course overwhelms the odds for more conventional diagnoses. In this case, a 39-year-old female patient who underwent bilateral lower limbs intradermal filllers presented with a two-year clinical course of repetitive flares of external bilateral hip tenderness, pain that limits her walking, soft-tissue nodular inflammation, redness, fever and a soft mobile nonpainful right supraclavicular lymphadenopathy. She sought medical attention at the Emergency Department in a community hospital of Framingham, Massachusetts, due to the aggravation of a repeated clinical episode. With a former diagnosis of recurrent bilateral soft-tissue infection, the patient underwent a novel approach different from the suspicion of a resistant pathogen towards the scope of a reminiscent granulomatous condition triggered by the two-year-old cosmetic para gluteal injections. After treatment with a course of systemic steroids and a deeper interrogation of past medical history, her clinical evolution highlighted the importance of seeking appropriate medical counseling prior undergoing cosmetic procedures. This is particularly critical for patients with a history of sarcoidosis, a granulomatous condition that can be flared even decades after the initial diagnosis when it meets specific triggers, such as intradermal injection. This risk is potentially heightened when such procedures are performed by underqualified providers who may lack the skill to gather a comprehensive medical history or, even worse, execute inadequate techniques or work in suboptimal environmental conditions, thereby increasing the potential for harm.