A 44-Year-Old Woman With Polyarthritis, Fever, and Hilar Adenopathy: Treatment
The presence of at least three of these criteria had a sensitivity of 93% and a specificity of 99% (Table 2). However, some authors have published case reports describing unusual difficulty with this diagnosis. Patients with sarcoidosis may have positive rheumatoid factor, and/or positive an-tinuclear antibody assays, and/or elevated uric acid levels, and these laboratory results can lead to confusion. Most patients with sarcoidosis (> 90%) have intrathoracic lymphadenopathy. Biopsies reveal non-caseating granulomas. However, similar results occur in patients with granulomatous infection and malignancy. Most patients with Lofgren syndrome have complete resolution of their symptoms, and this syndrome represents a benign acute presentation of sarcoidosis with a good prognosis. In the series of Lofgren, 102 patients (91.9%) had complete resolution of hilar adenopathy and infiltrates, if present, by 2 years. comments
In the series of Visser et al, all patients with acute sarcoid arthritis went into clinical remission within 3 months. Treatment with nonsteroidal antiinflammatory drugs or short courses of steroids is usually satisfactory. However, some patients can have a full recurrence of the syndrome. Patients with chronic sarcoidal arthritis usually have noncaseating granulomas on synovial biopsy, often have chronic skin disease, and usually acquire this complication during the course of chronic pulmonary sarcoidosis.
Mycobacterial infection involving joints is more prevalent in immunocompromised patients, the elderly, and immigrants from developing countries. It usually presents with monoarticular arthritis, but indolent oligoarthritis can develop. Isolation of the organism is usually necessary to establish the diagnosis. Culture of synovial fluid is positive in 80% of cases. Caseating or noncaseating granulomas can be found in joints and other tissues. Fungal arthritis is characterized by an insidious onset, an indolent course, and mild inflammation. The main diagnostic test is a positive culture finding from joint fluid or tissue. Coccidioides immitis, Blastomycosis dermiti-tidis, Cryptococcus neoformans, Histoplasma capsu-latum, and Aspergillus species are the most common pathogens. Whipple disease is a chronic systemic bacterial infection (Tropheryma whippelii) that predominantly affects middle-aged men. Unexplained, chronic, seronegative oligoarthritis or polyarthritis affecting the large-limb joints is the most common rheumatic presentation.
Table 2—Diagnostic Criteria for Sarcoid Arthritis
|Test Performance, %||
|Bilateral ankle arthritis||95||92||35||99.7|
|Bilateral ankle arthritis plussymptoms for < 2 mo||95||97||61||99.7|
|Bilateral ankle arthritis plussymptoms for < 2 mo plus age < 40 yr||85||99||78||99.3|
|a 3 of 4 criteria§||93||99||75||99.7|
Category: Respiratory Symptoms
Tags: erythema nodosum, granuloma, lofgren syndrome, sarcoid arthritis