A 44-Year-Old Woman With Polyarthritis, Fever, and Hilar Adenopathy: Laboratory and Radiographic Findings
Abnormal laboratory test results included glucose, 147 mg/dL; C-reactive protein, 5 mg/L (0.7 to 1.0 mg/dL); erythrocyte sedimentation rate, 44 mm/h; total complement, 88 U/mL (26 to 58 U/mL); and hepatitis B core antibody positive. CBC differential count, electrolytes, lever function, renal function, and creatine kinase were all within normal limits. Urinalysis showed hematuria and trace ketones. Rheumatoid factor, anti-streptolysin O, anti-nuclear antibody, anti-Smith antibody, anti-Smith/ribonucle-oprotein antibody, uric acid, Borrelia burgdorferi and parvovirus B19 serologies, angiotensin-converting enzyme levels, serum calcium, and purified protein derivative were all negative or within normal limits.
A human leukocyte antigen-B27 test was not performed. Chest radiography showed bilateral hilar adenopathy most prominent on the right side. Chest radiographs of the ankles, knees, wrists, and sacroiliac joints were within normal limits. CT scan of the chest showed numerous enlarged mediastinal lymph nodes in the precarinal and subcarinal areas, aorto-pulmonary window, and both hila (Fig 1, 2). Echocardiography showed a mild enlargement of both atria, normal left ventricular systolic function, trace mitral regurgitation, and no regional wall motion abnormalities. Right ankle arthrocentesis was performed, and fluid analysis showed WBC count of 463/^L; 13% neutrophils; 42% lymphocytes; 18% monocytes; 25% macrophages; 2% fluid lining cells; glucose, 99 mg/dL; protein, 1.6 g/dL; and negative bacterial and fungal culture results. No monosodium urate, calcium pyrophosphate, or cholesterol crystals were present. Mediastinal lymph node biopsy obtained using mediastinoscopy revealed noncaseating granulomas with negative acid-fast bacilli and Go-mori methenamine silver stains and negative CD1 immunostaining (a histiocytosis marker). Culture results from this biopsy were negative for bacteria and fungi. There was no evidence for lymphoma or malignancy. Pulmonary function tests were not performed. More info
Figure 1. Radiograph reveals bilateral hilar adenopathy, especially in the right inferior hilum.
Figure 2. CT with contrast reveals hilar adenopathy and mediastinal adenopathy adjacent to the left atrium.
Category: Respiratory Symptoms
Tags: erythema nodosum, granuloma, lofgren syndrome, sarcoid arthritis