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Doctor, I Think I Have Lofgren Syndrome. But Do You, Really?
Chest Infections SESSION TITLE: Fellow Case Report Poster - Chest Infections I SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM
Doctor, I Think I Have Lofgren Syndrome. But Do You, Really? Alice Gallo De Moraes MD* Rahul Sampath MBBS; and Megan Dulohery MD Mayo Clinic, Rochester, MN INTRODUCTION: Lofgren syndrome is the combination of erythema nodosum, hilar adenopathy, migratory polyarthralgia and fever. It is more common in women, has a 95% diagnostic specificity for sarcoidosis when all features are present and is associated with good prognosis and spontaneous remission2. This is the case of a patient who presented saying she had Lofgren Syndrome based on what she had read on the internet. CASE PRESENTATION: A 44-year-old woman from Minnesota, presented with hilar lymphadenopathy, migratory polyarthralgia, fever and painful rash on her shins. Symptoms started abruptly in the winter, with fevers, chills and night sweats associated with chest tightness and shortness of breath. She was treated for pneumonia, with no improvement. Her exposure history was significant only for backyard cleaning and building a pond in the previous summer. She had CT Chest and PET scan done, which showed bilateral hilar and mediastinal lymphadenopathy; they were highly FDG avid on PET scan. She underwent bronchoscopy with ultra sound guided transbronchial needle aspiration (TBNA). She also had fungal serologies and urinary antigens ordered. Pathology from skin biopsies and TBNA were positive for granulomas. The initial working diagnosis was Sarcoidosis with Lofgren Syndrome. However, her urinary antigen came back positive for Blastomyces. She was started on oral itraconazole.
CONCLUSIONS: Both Sarcoidosis and Blastomycosis are systemic granulomatous diseases. A high level of suspicion is essential to make an accurate diagnosis when a patient presents with a granulomatous disease to the Pulmonary Clinic Reference #1: Castillo CG et al. Infectious disease clinics of North America 2016;30:247-264 Reference #2: Shinn J et al. The Medical clinics of North America 2015;99:1123-1148 DISCLOSURE: The following authors have nothing to disclose: Alice Gallo De Moraes, Rahul Sampath, Megan Dulohery No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.128
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
119A
CHEST INFECTIONS
DISCUSSION: This case demonstrates the importance of maintaining a broad differential diagnosis, even when patients have “classic” presentations of rare diseases. Both sarcoidosis and blastomycosis are granulomatous diseases, noncaseating and pyogranulomatous, respectively. Both diseases most commonly affect the lungs, but can affect any organ 1,2. The diagnosis of sarcoidosis requires three elements: compatible clinical and radiographic manifestations, exclusion of other diseases that may present similarly and histopathological detection of noncaseating granulomas. While the definite diagnosis of blastomycosis requires the growth of the organism from a clinical specimen, the detection of fungal antigens in urine is useful for diagnosis and treatment of invasive disease.
Doctor, I Think I Have Lofgren Syndrome. But Do You, Really? Alice Gallo De Moraes MD* Rahul Sampath MBBS; and Megan Dulohery MD Mayo Clinic, Rochester, MN INTRODUCTION: Lofgren syndrome is the combination of erythema nodosum, hilar adenopathy, migratory polyarthralgia and fever. It is more common in women, has a 95% diagnostic specificity for sarcoidosis when all features are present and is associated with good prognosis and spontaneous remission2. This is the case of a patient who presented saying she had Lofgren Syndrome based on what she had read on the internet. CASE PRESENTATION: A 44-year-old woman from Minnesota, presented with hilar lymphadenopathy, migratory polyarthralgia, fever and painful rash on her shins. Symptoms started abruptly in the winter, with fevers, chills and night sweats associated with chest tightness and shortness of breath. She was treated for pneumonia, with no improvement. Her exposure history was significant only for backyard cleaning and building a pond in the previous summer. She had CT Chest and PET scan done, which showed bilateral hilar and mediastinal lymphadenopathy; they were highly FDG avid on PET scan. She underwent bronchoscopy with ultra sound guided transbronchial needle aspiration (TBNA). She also had fungal serologies and urinary antigens ordered. Pathology from skin biopsies and TBNA were positive for granulomas. The initial working diagnosis was Sarcoidosis with Lofgren Syndrome. However, her urinary antigen came back positive for Blastomyces. She was started on oral itraconazole.
CONCLUSIONS: Both Sarcoidosis and Blastomycosis are systemic granulomatous diseases. A high level of suspicion is essential to make an accurate diagnosis when a patient presents with a granulomatous disease to the Pulmonary Clinic Reference #1: Castillo CG et al. Infectious disease clinics of North America 2016;30:247-264 Reference #2: Shinn J et al. The Medical clinics of North America 2015;99:1123-1148 DISCLOSURE: The following authors have nothing to disclose: Alice Gallo De Moraes, Rahul Sampath, Megan Dulohery No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.128
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
journal.publications.chestnet.org
119A
CHEST INFECTIONS
DISCUSSION: This case demonstrates the importance of maintaining a broad differential diagnosis, even when patients have “classic” presentations of rare diseases. Both sarcoidosis and blastomycosis are granulomatous diseases, noncaseating and pyogranulomatous, respectively. Both diseases most commonly affect the lungs, but can affect any organ 1,2. The diagnosis of sarcoidosis requires three elements: compatible clinical and radiographic manifestations, exclusion of other diseases that may present similarly and histopathological detection of noncaseating granulomas. While the definite diagnosis of blastomycosis requires the growth of the organism from a clinical specimen, the detection of fungal antigens in urine is useful for diagnosis and treatment of invasive disease.