A 44-Year-Old Woman With Polyarthritis, Fever, and Hilar Adenopathy: Resolution within 3 months
What is the differential diagnosis in this patient with asymmetric large-joint oligoarthritis, fever, and bilateral hilar adenopathy?
How should this patient be treated?
What clinical course should be expected?
Diagnosis: Sarcoid arthritis consistent with Lofgren syndrome
Treatment: Nonsteroidal antiinflammatory drugs or corticosteroids
Our patient presented with subacute polyarthritis, bilateral hilar adenopathy, and fever. She did not have erythema nodosum. The differential diagnosis of polyarthritis and fever is extensive. The heuristic for limiting the number of possibilities will certainly depend on the clinician’s experience. The best approach might involve consideration of the frequency of various diseases, analysis of information clusters, or assessment of a predominant symptom, sign, or laboratory test. website
The presence of intrathoracic adenopathy should reduce the number of diagnostic possibilities. However, the list is still long and heterogeneous and would include fungal and mycobacterial infection, Whipple disease, systemic lupus erythematosus, Still disease, hereditary periodic fever syndromes, systemic vasculitis such as Wegener granulomatosus, reactive arthritis, lymphoma, and sarcoidosis. In this case, the lymph node biopsy sample was consistent with sarcoidosis, but operationally this should be considered a diagnosis of exclusion.
Sarcoidosis can have multiple clinical presentations, including arthritis, bilateral hilar adenopathy, and erythema nodosum. The initial publications of Lofgren included a series of 113 patients with erythema nodosum and bilateral hilar adenopathy (Table 1). One hundred four of these patients had fever. One hundred one patients had joint involvement. Considerable periarthritic edema was noted around the ankles. Other authors have described series of patients with acute sarcoid arthritis. Therefore, the clinical information and the authors’ perspective vary from series to series. Lofgren syndrome typically involves large joints, especially the knees and ankles, in a symmetrical and additive pattern. The ankle swelling in these patients may reflect acute arthritis, tenosynovitis, or tendonitis.
Table 1—Clinical Presentation in Lofgren Cases
|Clinical Variables||Patients, No.||Comment|
|Erythema nodosum and bilateral hilaradenopathy||113|
|Joint symptoms||101||Arthritis, n = 78; arthralgias, n = 23|
|Pulmonary disease on radiography|
|At presentation||10||Infiltrates: miliary, n = 12; reticular, n = 10|
|During follow-up||32||Miliary and reticular, n = 17; patchy, n = 3|
|Miscellaneous||9||Tonsils, thyroid, pituitary, bone, pancreas, stomach|
|Resolution||102||Within 2 yr|
Category: Respiratory Symptoms
Tags: erythema nodosum, granuloma, lofgren syndrome, sarcoid arthritis