Koebner Phenomenon: a Clinical Clue of Systemic Sarcoidosis

We have a 57 year old female with past medical history significant only for hypothyroidism and generalized lymphadenopathy who presents with acute behavioral changes. She was minimally responsive on exam, nonverbal, and only weakly able to follow basic commands such as squeezing her hands. Her physical exam was notable for scarring of bilateral eyebrows (figures 1 and 2), which occurred three years ago when she had cosmetic tattooing of her eyebrows. She was accompanied by her husband who states that she does not take any medications at home other than levothyroxine. Clinical testing including neuroimaging with CT and MRI, EEG, CBC/CMP, TSH, HIV, RPR, urine drug screen, and CSF analysis were all normal. On a previous admission, patient had a full-body CT performed which showed extensive lymphadenopathy throughout the neck, bilateral hila, mesentery, and retroperitoneum.