nodules together with arthralgia within one month, and the dose was then tapered gradually. However, polyarth- ralgia recurred after two years of treatment. Löfgren’s syndrome, an acute form of sarcoidosis, is characterized by erythema nodosum, bilateral hilar lymphadenopathy, and arthralgia. 1–4 It is a common form of sarcoidosis in Caucasian populations but not in Japa- nese subjects. It is usually a self-limiting disease, becom- ing inactive within the first two years. 5,6 Patients with this syndrome may have arthralgia, requiring NSAIDs, but corticosteroids are rarely required. In addition, the presence of erythema nodosum is a predictor of good prognosis in patients with sarcoidosis. 7 However, some patients with Löfgren’s syndrome are resistant to NSAIDs and show a chronic course. In the present case, symptoms persisted despite treatment with NSAIDs. Histopathologi- cal confirmation is important in establishing the diagnosis of sarcoidosis, including Löfgren’s syndrome, particularly if corticosteroid treatment is considered. It is necessary to exclude the possibility of diseases such as lymphoma, tuberculosis, fungal infection, berylliosis, and other condi- tions associated with hilar lymphadenopathy. Careful physical examination may reveal skin lesions suggestive of granulomatous lesions. More frequently, an asymptom- atic myopathy is present in patients with Löfgren’s syn- drome and other forms of sarcoidosis. The myopathy is frequently associated with systemic involvement, 8,9 although the link with specific organ damage is not known. Muscle biopsies in patients with sarcoidosis are useful for histological confirmation of granulomatous inflammation despite the absence of muscle symptoms. It has been recommended to biopsy the gastrocnemius mus- cle, which has a diagnostic yield of 20–75%. 5,8–10 We used high-frequency sonographic imaging for evaluation of myopathy and performed muscle biopsy based on these findings. High-frequency sonography is frequently used for evaluating the thickness of skin tumors in dermatol- ogy. As muscle biopsy is an invasive surgical procedure, accurate evaluation of muscle condition before the biopsy is essential to minimize patient discomfort. High-fre- quency sonography is a useful means of detecting muscle alterations, even in patients with no symptoms, and thus allows us to determine biopsy sites precisely. Atsuko Ohashi, MD Hiroshi Koga, MD Koichi Hayashi, MD, PhD Hisashi Uhara, MD, PhD Ryuhei Okuyama, MD, PhD Department of Dermatology Shinshu University School of Medicine Matsumoto Japan E-mail: rokuyama@shinshu-u.ac.jp References 1 Löfgren S, Lundbäck H. The bilateral hilar lymphoma syndrome; a study of the relation to tuberculosis and sarcoidosis in 212 cases. Acta Med Scand 1952; 142: 265–273. 2 Löfgren S, Lundbäck H. The bilateral hilar lymphoma syndrome; a study of the relation to age and sex in 212 cases. Acta Med Scand 1952; 142: 259–264. 3 Löfgren S. Primary pulmonary sarcoidosis. II. Clinical course and prognosis. Acta Med Scand 1953; 145: 465–474. 4 Löfgren S. Primary pulmonary sarcoidosis. I. Early signs and symptoms. Acta Med Scand 1953; 145: 424–431. 5 Mañá J, Gómez-Vaquero C, Montero A, et al. Löfgren’s syndrome revisited: a study of 186 patients. Am J Med 1999; 107: 240–245. 6 Glennås A, Kvien TK, Melby K, et al. Acute sarcoid arthritis: occurrence, seasonal onset, clinical features and outcome. Br J Rheumatol 1995; 34: 45–50. 7 Gran JT, Bøhmer E. Acute sarcoid arthritis: a favourable outcome? A retrospective survey of 49 patients with review of the literature. Scand J Rheumatol 1996; 25: 70–73. 8 Stjernberg N, Cajander S, Truedsson H, et al. Muscle involvement in sarcoidosis. Acta Med Scand 1981; 209: 213–216. 9 Silverstein A, Siltzbach LE. Muscle involvement in sarcoidosis. Asymptomatic, myositis, and myopathy. Arch Neurol 1969; 21: 235–241. 10 Wallace SL, Lattes R, Malia JP, et al. Muscle involvement in Boeck’s sarcoid. Ann Intern Med 1958; 48: 497–511. A rare human-to-human transmission of orf Editor, Orf is a zoonotic cutaneous infection caused by parapox- virus. It is usually transmitted through direct contact with infected small ruminants or their contaminated materials. Therefore, orf frequently develops on the hands and arms in humans. 1,2 Human-to-human transmission and facial involvement are extremely rare. 3–5 Here, we report a pre- sentation of orf on the face which had been transmitted from father to daughter via the common use of a pair of tweezers. A 16-year-old girl was admitted with a few fast grow- ing, reddish tumors and facial swelling. The lesions had appeared two weeks previously. The family’s medical history revealed that the patient’s father had developed a similar lesion on his right hand after making contact with ª 2013 The International Society of Dermatology International Journal of Dermatology 2014, 53, e1–e79 Correspondence e63