A 44-Year-Old Woman With Polyarthritis, Fever, and Hilar Adenopathy: Study
Periarticular inflammation with soft tissue swelling with no direct joint involvement is considered a variant of Lofgren syndrome. Ultrasound and MRI can provide an exact anatomic location of the inflammatory process. The joint fluid, if present, is usually mildly inflammatory with a WBC in the range of 4,000 to 15,000/^L and a predominance of lymphocytes. Synovial biopsy specimens typically reveal nonspecific proliferative inflammatory changes. Noncaseating granulomas are uncommon in the acute arthritic presentation. The association between articular involvement and erythema nodosum in patients with Lofgren syndrome is not constant. comments
Patients often have ankle involvement as an initial presentation, and then erythema nodosum appears 1 to 2 weeks later. However, Caplan et al described 19 patients in whom periarticular ankle inflammation was associated with bilateral hilar adenopathy without erythema nodosum. Pennec et al analyzed 16 patients and concluded that there was no difference between patients with and without erythema nodosum. The skin lesion in erythema nodosum is a panniculitis that presents with poorly defined very tender erythematous plaques and nodules. Biopsy specimens reveal widening of connective tissue septa secondary to edema and neutrophilic infiltration. Biopsy specimens from older plaques reveal lymphocytes, histocytes, multinucleated giant cells, and occasional eosinophils usually associated with septal fibrosis. These plaques do not contain noncaseating granulomas or areas of necrosis. Erythema nodosum is associated with the infections (including tuberculosis and fungal infections), drugs (eg, sulfonamides and oral contraceptives), inflammatory bowel disease, some malignant neoplasms, and sarcoidosis. Skin biopsy specimens obtained near inflamed joints in patients with Lofgren syndrome may reveal panniculitis, noncaseating granulomas, and/or nonspecific inflammation. The arthritis and skin lesions in this syndrome often precede hilar adenopathy by several weeks. In the series by Lofgren, hilar adenopathy developed in 104 patients after their presentation with erythema nodosum. Thirty-eight patients had paratracheal adenopathy. The chest radiographs usually do not reveal parenchymal infiltrates. Visser and coworkers identified 55 patients with acute sarcoid arthritis and compared them to 524 patients with other forms of acute arthritis. They identified four clinical criteria that helped make the diagnosis of acute sarcoid arthritis. These included symmetrical ankle arthritis, symptoms for < 2 months, age < 40 years, and erythema nodosum.
Category: Respiratory Symptoms
Tags: erythema nodosum, granuloma, lofgren syndrome, sarcoid arthritis