A 28-year-old African American woman returns to the physician for follow-up of persistent symptoms. She has had a low-grade fever, joint pains, a cough, and shortness of breath for one month. Two weeks ago, she was given a 5-day course of azithromycin without improvement of her symptoms. A chest x-ray showed bilateral upper lobe opacities. She was then prescribed a 10-day course of levofloxacin. She has not noticed any improvement and has now developed painful red bumps on her legs.
She has no other medical problems and takes no other medications. She lives in New York and denies recent travel or any sick contacts. She has been in a relationship with a new male partner for the last 2 months. She does not use tobacco, alcohol, or illicit drugs.
Her temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, pulse is 84/min, and respirations are 16/min. The patient's pulse oximetry is 94% on room air. Examination reveals crackles in the upper lungs bilaterally. Tender, erythematous, non-fluctuant nodules are present on the anterior surfaces of both legs. The remainder of the examination is unremarkable.
Repeat chest x-ray shows bilateral upper lobe opacities that are unchanged.
Which of the following is the most likely diagnosis?

Question

A 28-year-old African American woman returns to the physician for follow-up of persistent symptoms.  She has had a low-grade fever, joint pains, a cough, and shortness of breath for one month.  Two weeks ago, she was given a 5-day course of azithromycin without improvement of her symptoms.  A chest x-ray showed bilateral upper lobe opacities.  She was then prescribed a 10-day course of levofloxacin.  She has not noticed any improvement and has now developed painful red bumps on her legs.
She has no other medical problems and takes no other medications.  She lives in New York and denies recent travel or any sick contacts.  She has been in a relationship with a new male partner for the last 2 months.  She does not use tobacco, alcohol, or illicit drugs.
Her temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, pulse is 84/min, and respirations are 16/min.  The patient's pulse oximetry is 94% on room air.  Examination reveals crackles in the upper lungs bilaterally.  Tender, erythematous, non-fluctuant nodules are present on the anterior surfaces of both legs.  The remainder of the examination is unremarkable.
Repeat chest x-ray shows bilateral upper lobe opacities that are unchanged.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec193a_98c9_c41a_853d_d506ed028a63_MD0002_00 This patient's presentation is consistent with likely stage III sarcoidosis. More than 90% of individuals have pulmonary involvement, and pulmonary staging of sarcoidosis is determined by chest x-ray findings; however, this classification has no correlation with disease severity. Symptomatic disease is seen more often in African Americans than Caucasians and usually presents with cough, dyspnea, and chest pain. Skin involvement occurs in up to 25% of patients, and erythema nodosum is the most common lesion. Erythema nodosum represents panniculitis and should not be biopsied to confirm a diagnosis of sarcoidosis. Lofgren's syndrome (i.e., erythema nodosum, hilar adenopathy, migratory polyarthralgias, and fever) is seen more commonly in women with sarcoidosis and tends to resolve spontaneously with a good prognosis. (Choice A) Pulmonary symptoms with an abnormal chest x-ray are common in previously infected HIV patients with CD4 counts < 200 cells/mm³. However, it is not common during acute HIV, which causes a self-limited mononucleosis-like illness. In addition, erythema nodosum is less common in HIV disease. ³ (Choice B) Right-sided endocarditis can result in septic emboli. Septic emboli appear as peripheral wedge-shaped infarcts with evidence of cavitation in some of the lesions. Right-sided endocarditis is frequently seen in intravenous drug abusers. (Choice C) Acute mycobacterial disease is a granulomatous disease with symptoms and x-ray findings similar to sarcoidosis. Acute disease most often presents with hilar adenopathy and pulmonary symptoms, whereas reactivation disease is usually seen in the upper lobes. However, erythema nodosum is very rare in mycobacterial disease and has only been described in a few case reports. (Choice D) Nocardiosis can present with skin lesions that range from pyogenic skin abscesses to cellulitis, and may be mistaken for erythema nodosum. Although Nocardia tends to cause symptomatic pulmonary disease in the upper lobes, it is usually not associated with erythema nodosum. Nocardia also tends to occur more commonly in immunocompromised states, which are not present in this patient. Educational objective: Sarcoidosis may present in symptomatic patients with pulmonary symptoms, an abnormal chest x-ray, and erythema nodosum. Staging of pulmonary sarcoidosis is based on chest radiograph appearance. Stage III and IV patients do not have the classic bilateral hilar adenopathy. Diagnosis of sarcoidosis requires suggestive clinical and radiographic findings, exclusion of similarly presenting conditions, and tissue biopsy showing noncaseating granulomas. __________ References: Diagnosis of sarcoidosis. (http://www.ncbi.nlm.nih.gov/pubmed/18664976) Characteristics of patients presenting with erythema nodosum and sarcoidosis (http://www.ncbi.nlm.nih.gov/pubmed/19722355)

A 28-Year-Old African American Woman Returns to the Physician for Follow-Up