Male presenting with bilateral ankle arthritis? Request a chest X-ray!

Abstract

A 30-year-old Caucasian male was referred to the Internal Medicine Department of our hospital for consultation with a self-limiting history of bilateral ankle pain with edema, beginning 6 weeks before (Fig. 1). He was a professional cook and a non-smoker, and he had no past medical or surgical history. He denied fever, myalgia, coughing, dyspnea, conjunctivitis, and urethral discharge and stated that he had not taken any drugs or been administered vaccines recently. He had initially seen his primary care physician and had complied with the prescribed bed rest along with acetaminophen. There was a complete remission of his symptoms within 2 weeks. Blood panel tests ordered by his primary care physician revealed an erythrocyte sedimentation rate of 37 mm/h (normal range 1–13 mm/h) and a C-reactive protein level of 2.6 mg/dL (normal range \ 0.5 mg/dL). The results of a complete blood count, hepatic enzymes, and renal and thyroid function were within the normal range, as were the results of the urinalysis and protein electrophoresis. The antistreptolysin O, rheumatoid arthritis (RA), and Venereal Disease Research Laboratory (VDRL) tests were all negative. A chest X-ray revealed prominent hila, mainly on the right side, without the presence of lesions in the lung parenchyma (Fig. 2). Ankle X-rays were normal. Being unable to find an objective diagnosis for this clinical picture, his primary care physician requested a consultation with the Department of Internal Medicine. The physical examination performed during this consultation was unremarkable. There were no signs of hepatosplenomegaly, palpable adenopathy, or erythema nodosum, and the ankles showed no signs of inflammation. The conclusive negative tests were: antistreptolysin O, RA-test, VDRL test, antinuclear antibodies and serology for Borrelia burgdorferi, Parvovirus B19, Epstein–Barr virus, cytomegalovirus, hepatitis B and C viruses, and human immunodeficiency virus (HIV) 1 and 2. The serum levels of uric acid, angiotensin converting enzyme, and calcium were normal. The erythrocyte sedimentation rate was still elevated (36 mm/h), but the C-reactive protein level was 0.6 mg/dL, with a normal hemogram. A chest computed tomography (CT) scan, carried out 1 week post-clinical evaluation, revealed a millimetric hilar and paratracheal adenopathies on the right side as well as two small parenchymal lesions suggestive of granulomas in the left superior pulmonary lobe (Fig. 3). These findings led to the conclusive diagnosis of Löfgren’s syndrome. At 6 months post-clinical examination, the patient remains asymptomatic. The results of the laboratory workup and the respiratory function tests are still normal, and the most recent chest CT-scan showed no parenchymal lesions or adenopathies. An allelic study revealed the presence of alleles HLA-DRB1*0301/DQB1*0201. Löfgren’s syndrome, first described in 1952 by Swedish pneumologist Sven Löfgren, is considered to be an acute benign variation of sarcoidosis [1]. It is characterized by the presence of erythema nodosum and bilateral hilar J. Figueira-Coelho P. Mendonça Department of Medicine I, Hospital de Curry Cabral, Rua da Beneficência n88, 1069-166 Lisbon, Portugal

DOI: 10.1007/s10165-010-0314-6

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Cite this paper

@article{FigueiraCoelho2010MalePW, title={Male presenting with bilateral ankle arthritis? Request a chest X-ray!}, author={Jo{\~a}o Figueira-Coelho and Paula Mendonça}, journal={Modern rheumatology}, year={2010}, volume={20 6}, pages={640-2} }