A 26-year-old woman is evaluated for joint pain affecting the elbows, knees, and ankles for the past month. She has also experienced a dry cough and mild shortness of breath over the last 6 months. She is sexually active and takes oral contraceptives. Temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, pulse is 84/min, and respirations are 16/min. On physical examination, the lungs are clear to auscultation. There is mild swelling and tenderness of the elbows, knees, and ankles. The lower extremities are tender to palpation and have scattered erythematous nodules. Chest x-ray reveals lung nodules and hilar fullness. Transbronchial biopsy shows large epithelioid cells, occasional giant cells, and no areas of necrosis. Which of the following pharmacotherapies is most appropriate for the initial treatment of this patient?

Question

A 26-year-old woman is evaluated for joint pain affecting the elbows, knees, and ankles for the past month.  She has also experienced a dry cough and mild shortness of breath over the last 6 months.  She is sexually active and takes oral contraceptives.  Temperature is 37.2 C (99 F), blood pressure is 120/70 mm Hg, pulse is 84/min, and respirations are 16/min.  On physical examination, the lungs are clear to auscultation.  There is mild swelling and tenderness of the elbows, knees, and ankles.  The lower extremities are tender to palpation and have scattered erythematous nodules.  Chest x-ray reveals lung nodules and hilar fullness.  Transbronchial biopsy shows large epithelioid cells, occasional giant cells, and no areas of necrosis.  Which of the following pharmacotherapies is most appropriate for the initial treatment of this patient?

Quizplus · Accepted Answer

11ec160b_3a1d_9082_9249_e36daac4da63_MD0001_00 This young patient has arthralgias, dyspnea, cough, and erythema nodosum (tender, subcutaneous, lower extremity nodules). This, in conjunction with lung nodules and hilar fullness on x-ray, is highly suggestive of sarcoidosis, an inflammatory disease characterized by granuloma formation in multiple tissues. Diagnosis is confirmed by biopsy showing noncaseating granulomas composed of epithelioid cells (activated macrophages) and giant multinucleated cells without central necrosis. Typical manifestations include hilar adenopathy, pulmonary infiltrates (eg, nodules, interstitial lung disease), skin (eg, erythema nodosum) and ocular (eg, anterior uveitis) involvement, polyarthritis, and constitutional symptoms (eg, fatigue, weight loss). Many patients with sarcoidosis do not require treatment; however, those with significant symptoms (eg, dyspnea, chest pain) or progressive pulmonary disease (ie, worsening opacities/fibrosis or pulmonary function tests) should be treated. Oral glucocorticoids (eg, prednisone) are the initial treatment of choice. (Choice A) Ceftriaxone is appropriate treatment for disseminated gonococcal infection, which causes arthralgias and tenosynovitis. However, patients typically have a pustular, painless dermatitis; lung involvement would be unexpected. (Choice B) Doxycycline is used to treat Lyme disease, which presents with an expansive erythematous rash with central clearing (erythema migrans), fatigue, and arthralgias; pulmonary involvement is unexpected. Histology demonstrates an inflammatory infiltrate with spirochetes. (Choice C) Etanercept is a tumor necrosis factor-alpha inhibitor that is used in rheumatoid arthritis, a condition that can cause arthralgias, skin nodules (rheumatoid nodules), and interstitial lung disease; however, it typically involves the metacarpophalangeal and proximal interphalangeal joints. Pathology shows a periarticular inflammatory infiltrate with joint destruction; noncaseating granulomas would not be seen. (Choice D) Penicillin is used to treat syphilis, but the rash associated with this disease is typically maculopapular and involves the palms and soles. Histopathology may demonstrate lymphoplasmacytic inflammation and granulomas, and Treponema pallidum is visible on darkfield microscopy. Educational objective: Sarcoidosis commonly presents with hilar adenopathy, pulmonary infiltrates, and skin findings (eg, erythema nodosum). Biopsy shows noncaseating granulomas composed of epithelioid cells (activated macrophages) and giant multinucleated cells. Oral glucocorticoids are the initial treatment of choice.

A 26-Year-Old Woman Is Evaluated for Joint Pain Affecting the Elbows