Lofgren's Syndrome-Acute Onset Sarcoidosis and Polyarthralgia: A Case Report
A 44-year-old woman was admitted to our hospital in June 2011 complaining of arthralgia in both knees, elbows, and ankles. She had been diagnosed with hepatic cysts 10 years ago but was healthy before the appearance of bilateral polyarthritis of the knees 1 month before admission. She went to a nearby orthopedic clinic and reported temporary alleviation of the knee pain upon taking non-steroidal anti-inflammatory drugs (NSAIDs).\nA physical examination showed mild swelling and tenderness in both ankles without limitation of range of motion. Laboratory studies showed elevated erythrocyte sedimentation rate (ESR, 39 mm/hr) and C-reactive protein level (CRP, 45.79 mg/L) (). White blood cell count was 8,600/L, blood hemoglobin was slightly low at 11.4 g/dL, and platelet count was 290,000/L. The serum angiotensin-converting enzyme (ACE) level was (29.0 IU/L; normal range, 7.7-29.4 IU/L). Aspartate aminotransferase (AST) and alanine transaminase (ALT) levels were slightly high at 37 IU/L and 60 IU/L, respectively. She was negative for rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) antibody. Her C3 level was 144 mg/dL, C4 was 34 mg/dL, and antinuclear antibody was positive at a titer of 1:80 (homogeneous and fine cytoplasmic granules pattern), but specific antibodies were not detected ().\nKnee, ankle, hip, and hand X-ray findings showed periarticular osteoporosis (). Ultrasonography findings suggested polyarticular inflammatory synovitis of both knees, elbows, ankles, with a combined partial tear of common extensor tendons in both elbows.\nChest X-ray findings showed focal mediastinal widening in both the hilum and the right upper trachea (), and chest computed tomography scan indicated multiple enlarged lymph nodes of the mediastinum and both hila (). The bone scan showed mildly increased uptake in bilateral hands, wrists, and other small joint areas ().\nA mediastinoscopic lymph node biopsy was performed. The obtained tissues of mediastinal lymph nodes showed noncaseating granuloma of epithelioid cells and the presence of giant cells ().\nBased on the bilateral hilar lymphadenopathy (BHL) with polyarthralgia, the patient was diagnosed with Lofgren's syndrome, although EN. NSAID treatment did not alleviate her symptoms for 1 week. Oral administration of prednisolone (10 mg/day) was initiated. The pain resolved within 1 week, and the levels of ESR and CRP were normalized after 2 weeks (12 mm/hr, 4.96 mg/L). The prednisolone dose was lowered 1 month later (5 mg/day). The pain and joint swelling were improved, but she sometimes felt mild pain in the joints, and BHL was still seen on simple chest radiography after 2 months. For these reasons, prednisolone administration has been continued for 8 months until now. No recurrence has been observed since then.