A 32-year-old man comes to the office due to right-sided facial weakness for 3 days. He has had no fever, headache, vision disturbances, or extremity weakness or numbness but has been extremely fatigued over the past several months. The patient has no prior medical conditions and takes no medications. He drinks alcohol occasionally and does not use tobacco or illicit drugs. The patient lives in coastal California and has not traveled recently. Vital signs are within normal limits. Physical examination reveals right-sided facial droop with flattening of the nasolabial fold. He is unable to elevate the right eyebrow or close the right eye completely. Upper and lower extremity muscle strength, deep tendon reflexes, and sensation are normal on both sides. There is no neck rigidity. The lungs are clear on auscultation, and heart sounds are normal. Hepatosplenomegaly is present. The cervical, axillary, and inguinal lymph nodes are multiple, firm, and nontender. No skin rash or extremity edema is present. The joints are not swollen or tender. Item 1 of 2 Which of the following is the best initial test for this patient?

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Explanation: 11ec2b69_c002_76c3_8f63_3de048ff658a_MD0005_00 This young patient's unilateral facial nerve palsy, hepatomegaly, and lymphadenopathy raise suspicion for extrapulmonary sarcoidosis. Sarcoidosis is a multisystem granulomatous disease of unknown origin that primarily affects young adults. Most cases involve the lungs, but extrapulmonary manifestations frequently (~30%) occur and can be the presenting feature. The following sites are commonly involved: Skin: papular, nodular, or plaque-like lesions or erythema nodosum Eyes: uveitis and keratoconjunctivitis sicca Joints: acute polyarthritis Nervous system: facial nerve palsy Reticuloendothelial system: hepatomegaly (~20%) and peripheral lymphadenopathy (~40%) Extrapulmonary sarcoidosis is almost always accompanied by significant fatigue. Screening for suspected cases usually begins with a chest x-ray because >90% of patients have bilateral hilar or mediastinal adenopathy. Additional testing is then typically required for confirmation. (Choice A) Herpes simplex meningitis is often associated with focal neurologic findings (eg, cranial nerve deficits) and is usually diagnosed with cerebrospinal fluid PCR. However, most patients have fever (>90%) and altered mental status. Peripheral lymphadenopathy and hepatomegaly would be atypical. (Choice C) Early disseminated Lyme disease can cause facial nerve palsy (~8%) and is usually diagnosed with Lyme serology. Flu-like symptoms and lymphadenopathy can also occur. However, this patient lives in coastal California, where Lyme disease is less prevalent, and hepatosplenomegaly is not a typical feature of Lyme disease. (Choice D) Patients with facial nerve palsy should undergo neuroimaging if they have red flag symptoms (eg, sparing of the upper face, associated hearing loss, associated facial twitching) or if their condition continues to worsen after 3 weeks or fails to resolve by 4 months. This patient with upper and lower facial weakness, peripheral lymphadenopathy, and hepatomegaly is less likely to have a CNS lesion. (Choice E) Patients with CNS tuberculosis can develop cranial nerve palsies and fatigue. However, the majority of cases are associated with 2-3 weeks of prodromal symptoms (eg, headache, low-grade fever, personality changes) and prominent meningeal signs (eg, nuchal rigidity). Educational objective: Sarcoidosis is a multisystem granulomatous disease. The lungs are most commonly affected, but extrapulmonary manifestations of the skin (eg, erythema nodosum), eyes (eg, uveitis), joints (eg, acute polyarthritis), nervous system (eg, facial nerve palsy), and reticuloendothelial system (eg, hepatosplenomegaly, lymphadenopathy) commonly occur. Chest x-ray is often the first screening test because >90% of patients have bilateral hilar or mediastinal adenopathy. References: Extrapulmonary manifestations of sarcoidosis. (http://www.ncbi.nlm.nih.gov/pubmed/23597964) Neurologic manifestations of sarcoidosis. (http://www.ncbi.nlm.nih.gov/pubmed/24365304)

A 32-Year-Old Man Comes to the Office Due to Right-Sided