Case: A 30-year-old woman presents to her physician’s office with 3 months of non-productive cough, exertional dyspnea, fatigue, malaise, and blurred vision. She denies weight loss, fever, chills, sweats, recent travel, or sick contacts. She works on the assembly line of an electronics plant. Vital signs are unremarkable. Physical examination reveals she has tender red papules over her shins. The patient said she first noticed the bumps when she changed oral contraceptive pills (her only medication), but assumed they would disappear. X-ray of the chest shows bilateral hilar lymphadenopathy with pulmonary infiltrates.
(A) Berylliosis Answer A is incorrect. Workers in high-technology fields, such as aerospace, nuclear, and electronics plants, ceramics industries, plating facilities, dental material sites, and dye manufacturing, can develop an interstitial lung disease called berylliosis. In berylliosis, x-ray of the chest shows bilateral hilar lymphadenopathy with interstitial infiltrates, and a biopsy of the lesion shows noncaseating granulomas. Both findings are similar to sarcoidosis. Distinction can be made between sarcoidosis and berylliosis by measuring tissue levels of beryllium. While the patient does work in an electronics plant and may have a component of berylliosis, the overall clinical picture is more consistent with sarcoidosis.
(B) Fungal infection Answer B is incorrect. The distinction between pulmonary fungal infection and sarcoidosis is important. After all, starting a patient on systemic steroids for sarcoidosis can be disastrous if the patient actually has a fungal infection. However, the clinical picture is more consistent with sarcoidosis, and the negative bronchoalveolar lavage culture argues against a fungal infection.
(C) Lymphoma Answer C is incorrect. The x-ray of the chest may be consistent with lymphoma, either Hodgkin’s or non-Hodgkin’s. However, the patient lacks the symptoms and signs typically present in lymphoma patients: fever temperature > 38.5°C [101.3°F]), night sweats, 10% weight loss over the preceding 6 months, and hepatosplenomegaly.
(E) Tuberculosis Answer E is incorrect. While the x-ray of the chest can also be indicative of pulmonary tuberculosis (TB), it is difficult to explain the other findings present in the case by this diagnosis. TB does not cause hypercalcemia or erythema nodosum. Rather, findings sometimes seen in TB, but not present in this patient, are hyponatremia from the syndrome of inappropriate secretion of antidiuretic hormone, leukocytosis, fever, and chest pain.
(D) Sarcoidosis The correct answer is D. The combination of constitutional symptoms, respiratory complaints, erythema nodosum, blurred vision, and bilateral hilar lymphadenopathy in a young adult strongly suggests the diagnosis of sarcoidosis; however, a biopsy of the pulmonary lymphadenopathy, which showed noncaseating granulomas, would be necessary to make a definitive diagnosis. Bilateral hilar lymphadenopathy on x-ray of the chest is pathognomonic for sarcoidosis, but a similar pattern can be seen in lymphoma, tuberculosis, fungal infection, and brucellosis. Elevated serum angiotensin-converting enzyme levels and hypercalcemia are other findings characteristic of sarcoidosis. The Kveim-Siltzbach skin test, which entails an intradermal sarcoid protein injection and is positive in 70–80% of patients, is now less commonly used with the advent of transbronchial biopsy of lung parenchyma.
A review of Sarcoidosis: Sex: Age: Higher incidence in (Race): Important symptoms: Skin: Eye: female Blacks Non-productive cough, Exertional dyspnea Erythema nodosum, Lupus pernio, plaques, maculopapular eruptions, subcutaneous nodules Anterior uveitis, conjunctivits, retinal infalmmation, loss of visual acuity or blindness
Bilateral dactylitis is present, along with chronic granulomatous skin lesions. Lupus pernio
Sarcoidosis_conjunctival granuloma Sarcoidosis Multinucleated Giant Cell with Asteroid Body, Lymph Node
Minicase 1: A 55-year-old man arrives at your office with a severe epigastric pain, nausea and vomiting. On physical examination his abdominal sounds are reduced. He reports the history of gallstones in the past 3 years. Laboratory tests show an elevation in serum amylase level. Acute pancreatitis
Minicase 2: A 7-year-old girl presents to your office with generalized edema. UA shows heavy selective proteinuria and lipiduria. After performing biopsy, no specific pathology is found on light microscopy. Minimal change disease
One approach to the work-up the chief complaint (CC) by asking some questions using the mnemonic SOCRATESSS: Site Onset Character Radiation Alleviating factors Timing Exacerbating factors Severity 1-10 Similar symptoms Sx
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