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* bilateral hilar lymphadenopathy
 #305673  
  vanco - 05/27/08 18:17
 
  A 30-year-old Scandinavian female presents with 2 weeks history of bilateral ankle pain. She also reports fever, easy fatigability, and loss of appetite. On examination, she has bilateral tender cutaneous nodules over the anterior surface of the legs. Her chest-X ray reveals bilateral hilar lymphadenopathy. Laboratory tests show elevated ESR, mild elevation of rheumatoid factor and positive antinuclear antibodies. Examination of other systems is unremarkable. Her vitals are stable except a temperature of 99.9F. What is the most likely diagnosis?

A. Lofgren’s syndrome.
B. Heerfordt-Waldenstrom syndrome.
C. Chronic sarcoidosis.
D. Tuberculosis.
E. Hodgkin’s lymphoma.
F. Rheumatoid arthritis.
G. Systemic lupus erythematosus

 
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* Re:bilateral hilar lymphadenopathy
#1327839
  capsule - 05/27/08 18:19
 
  A.  
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* Re:bilateral hilar lymphadenopathy
#1327846
  drhussain08 - 05/27/08 18:24
 
  A.  
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* Re:bilateral hilar lymphadenopathy
#1327848
  smiles11 - 05/27/08 18:26
 
  aa  
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* Re:bilateral hilar lymphadenopathy
#1327870
  mimra2008 - 05/27/08 18:37
 
  aa  
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* Re:bilateral hilar lymphadenopathy
#1327873
  vanco - 05/27/08 18:42
 
  Sarcoidosis is basically two types: Acute and chronic. Lofgren’s syndrome is an acute form of sarcoidosis predominantly seen in Scandinavian, Irish, and Puerto Rican woman. The characteristic presentation consists of triad of arthritis (of ankles, knees, wrists or elbows), erythema nodosum and bilateral hilar adenopathy. Lung involvement is very rare in this acute form. Laboratory studies suggest inflammatory disease with elevated ESR, false positive rheumatoid factor, and antinuclear antibodies.

Choice (B): Heerfordt-Waldenstrom syndrome is another rare from of acute sarcoidosis consists of fever, parotid enlargement, anterior uveitis, and facial nerve palsy.

Choice (C): Chronic sarcoidosis has an insidious onset that develops over months. It mainly presents with respiratory complaints without constitutional symptoms. Very few patients have organs other than lung involved. It leads to permanent lung damage.

Choice (D): Tuberculosis presents with constitutional symptoms such as fatigue, weight loss, anorexia, low-grade fever and night sweats. Pulmonary symptoms include cough, with purulent sputum or hemoptysis. Chest X ray reveals hilar and mediastinal lymphadenopathy, small infiltrates, pleural effusion and segmental atelectasis. Bilateral ankle arthritis is not a future of tuberculosis (TB).

Choice (E): Hodgkin’s lymphoma usually presents with fever, weight loss, night sweats, and generalized pruritus. These patients have painless lymphadenopathy that becomes painful with alcohol ingestion. Again, this acute presentation is classic for acute sarcoidosis.

Choice (F): Rheumatoid arthritis is associated with systemic symptoms such as fever, malaise, and weight loss. Morning joint stiffness lasting for more than 30 minutes is a characteristic feature. They usually involve metacarpophalangeal joints (MCP) and proximal interphalangeal joints (PIP) involvement. The joints are symmetrically involved and have obvious signs of inflammation. ESR is always elevated. Bilateral hilar lymphadenopathy is not classic for systemic lupus erythematosus (SLE).

Choice (G) Systemic lupus erythematosus presents with fever, malaise, and weight loss. These patients have a characteristic butterfly rash over the face. Majority of patients have joint symptoms usually non-debilitating. Serologic findings include anti nuclear antibody with high titer to native DNA. Bilateral hilar lymphadenopathy is not classic for SLE.

Educational Objective:
Lofgren’s syndrome is an acute form of sarcoidosis and consists of triad of bilateral ankle arthritis (some times knees, wrists or elbows), erythema nodosum and bilateral hilar adenopathy.

 
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