Australian Regenerative Medicine Institute

A 44-Year-Old Woman With Polyarthritis, Fever, and Hilar Adenopathy: Recommendation

Lymph nodes in these patients have histologic changes typical for Wegener granulomatosus. Sixty-seven percent of Wegener granulomatosus patients will have musculoskeletal symptoms at some time during their disease course. These usually consist of arthralgias and myalgias. However, 28% of these patients will have arthritis. The various patterns include monoarticular arthritis, migratory oligoarthritis, and asymmetrical polyarthritis involving both large and small joints. The arthritis is usually nonerosive and nondeforming; the knee is the most frequently involved joint. Ninety percent of patients with active Wegener granulomatosus have a positive anti-neutrophil cytoplasmic antibody test result. Of course, these patients typically present with a necrotizing granulomatous vasculitis involving the upper airway, lungs, and/or kidneys. The chest radiographs usually reveal multiple nodular infiltrates with cavitation.
Our patient had subacute oligoarthritis involving larger joints and hilar and mediastinal adenopathy with noncaseating granulomas. She had no skin lesions, and she had no evidence of parenchymal lung disease. Her presentation is consistent with Lofgren syndrome. The pathology and the various cultures ruled out granulomatous infection and malignancy. She was treated with steroids for 1 month and had a complete resolution of articular symptoms.
Clinical Pearls
1.    Joint fluid analysis should be performed in any patient presenting with large-joint arthritis and fever.
2.    The differential diagnosis of nonbacterial arthritis is extensive. Patients with ankle arthritis, hilar adenopathy, and erythema nodosum may have Lofgren syndrome. However, erythema nodosum is not a constant feature of Lofgren syndrome.
3.    The arthritic component of Lofgren syndrome may actually reflect periarticular inflammation. Ultrasound studies can locate the inflammatory process.
4.    The clinical criteria reported by Visser and coworkers will help identify acute sarcoid arthritis, but careful clinical follow-up is important.
5.    Patients with acute sarcoid arthritis usually have a good prognosis and respond well to nonsteroidal antiinflammatory drugs or short courses of steroids. Recurrence is unusual.

Category: Respiratory Symptoms

Tags: erythema nodosum, granuloma, lofgren syndrome, sarcoid arthritis