A 38-year-old Puerto Rican woman comes to the physician because of fever and fatigue for the last two weeks. Over the past few days, she has developed bilateral pedal edema, ankle pain with walking, and painful bruises on her shins without any trauma. She denies diarrhea, vaginal discharge, or lower abdominal pain. Her weight has been stable. She has no travel history within the past year. She denies tobacco, alcohol, or illicit drug use. She is in a monogamous relationship with her long-standing, live-in boyfriend and uses oral contraceptives.
Her temperature is 38.1 C (100.5 F), blood pressure is 122/70 mm Hg, and pulse is 86/min. Chest examination is unremarkable. The liver span is 11 cm and the tip of the spleen is not palpable. There are several violaceous, tender, raised lesions over both pretibial areas and 1+ pretibial edema. Both ankles are warm to the touch with some discomfort on passive movement.
Complete blood count, comprehensive metabolic panel, and urinalysis are all within normal limits.
Which of the following would be most useful in establishing the diagnosis in this patient?

Question

A 38-year-old Puerto Rican woman comes to the physician because of fever and fatigue for the last two weeks.  Over the past few days, she has developed bilateral pedal edema, ankle pain with walking, and painful bruises on her shins without any trauma.  She denies diarrhea, vaginal discharge, or lower abdominal pain.  Her weight has been stable.  She has no travel history within the past year.  She denies tobacco, alcohol, or illicit drug use.  She is in a monogamous relationship with her long-standing, live-in boyfriend and uses oral contraceptives.
Her temperature is 38.1 C (100.5 F), blood pressure is 122/70 mm Hg, and pulse is 86/min.  Chest examination is unremarkable.  The liver span is 11 cm and the tip of the spleen is not palpable.  There are several violaceous, tender, raised lesions over both pretibial areas and 1+ pretibial edema.  Both ankles are warm to the touch with some discomfort on passive movement.
Complete blood count, comprehensive metabolic panel, and urinalysis are all within normal limits.
Which of the following would be most useful in establishing the diagnosis in this patient?

Quizplus · Accepted Answer

11ec193a_9924_8e0a_853d_63f3f4e6b39a_MD0002_00 This patient's presentation is consistent with Löfgren's syndrome, a variant of sarcoidosis. Löfgren's syndrome classically presents with the triad of hilar adenopathy, erythema nodosum, and acute polyarthritis. The arthritis typically involves both ankles (> 90% of cases) and other large joints in the lower extremities. Because the presentation is so classical, Löfgren's syndrome does not require a tissue biopsy and can be diagnosed based on clinical presentation alone. Patients with suspected Löfgren's syndrome usually require chest imaging (e.g., chest CT if chest x-ray is negative) to identify hilar adenopathy. This variant of sarcoidosis is usually self-limiting, with a favorable long-term prognosis. Although no controlled trials are available, NSAIDs usually offer symptomatic relief and corticosteroids are generally not utilized. (Choice B) HIV infection can present with systemic symptoms, as seen in this patient, but is not usually associated with ankle involvement and erythema nodosum. The rash in HIV is often generalized, maculopapular, and frequently involves the mucous membranes. (Choice C) Although rheumatoid arthritis may present with joint disease and fatigue, it is usually not associated with erythema nodosum. (Choice D) Tuberculosis may present with hilar adenopathy and erythema nodosum (very rare), but less commonly with ankle involvement. This patient should first undergo chest imaging to evaluate for hilar adenopathy before tuberculin skin testing, since her presentation is more consistent with Löfgren's syndrome. (Choice E) Disseminated gonococcal infections can present with either purulent monoarthritis or as a triad of skin rash, tenosynovitis, and polyarthralgia without purulent monoarthritis. Tenosynovitis is quite specific for gonococcal infection. The associated skin rash is usually pustular or vesiculopustular. Symmetric joint involvement is uncommon. Educational objective: The combination of erythema nodosum, bilateral ankle arthritis, and bilateral hilar adenopathy has a high specificity for Löfgren's syndrome (a variant of sarcoidosis). The syndrome is usually self-limited and has an excellent short- and long-term prognosis. Although no controlled trials are available, NSAIDs usually offer symptomatic relief and corticosteroids are generally not required. __________ References: Sex-specific manifestations of Lofgren's syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/17023727) Sarcoid arthritis: clinical characteristics, diagnostic aspects and risk factors. (http://www.ncbi.nlm.nih.gov/pubmed/12006321)

A 38-Year-Old Puerto Rican Woman Comes to the Physician Because