A 35 year old African American woman who is a teacher at local elementary school presents for further evaluation after a recent visit to urgent care showed abnormal chest x-ray with bilateral hilar adenopathies. She went to urgent care because of cough, shortness of breath and chest pain. She has also noted low grade fever, malaise, and weight loss. In the past she was seen by an ophthalmologist for eye inflammation. She does not recall what they told her about her diagnosis. She is married and has three health children. She has not been on any new medications
She does admit to a red painful round and elevated rash on her legs that comes and goes, low grade fever, dry mouth and dry eyes, palpitations, facial swelling, palpitations, but admits to generalized weakness, being tiered all the time, and joint pain and swelling in her ankles over the last two months.
Recent evaluation included a CBC with diff. LFTs except for elevated alkaline phosphatase, Immunoglobulins, CPK, and UA that were all normal. Her ESR was elevated at 40. Vitamin D was low at 10. Her TB test was negative. Her EKG was normal.
Her examination is remarkable for tender round red and elevated skin lesions as well as swelling and tenderness in both ankles.
She had a HRCT of chest revealed Hilar and Mediastinal adenopathy. There were mid to upper zone lung involvement. She underwent a biopsy.
At this time you would recommend starting treatment with:
- Glucocorticoids
- Methotrexate
- Plaquinel
- Azathioprine
The answer is Glucocorticoids.
Methotrexate as well as other drugs can be used if:
- Patient can not or will refuse to take glucocorticoids
- Patient fails treatment with glucocorticoid
- Significant side-effects from steroids
- Need another drug to help taper glucocorticoids
Here are the important points incorporated here based on reading the info on sarcoidosis on uptodate. You need to point these out as I did below.
A 35 more common in this age group year old African American more common in african american woman who is a teacher at local elementary little chance of other issues like exposure to occupational exposure school who lived in Maryland all of her life no travel to areas like Alabama to pick up histoplasmosis presents for further evaluation after a recent visit to urgent care showed abnormal chest x-ray with bilateral hilar adenopathies. She went to urgent care because of Here are the very common symptoms cough, shortness of breath and chest pain stay away from not so common symptoms or rare symptoms. She has also noted low grade fever, malaise, and weight loss again more common symptoms. In the past she was seen by an ophthalmologist for eye inflammation past evaluation for uveitis. She does not recall what they told her about her diagnosismaking things vague. She is married and has three health childrenlittle chance of STD such as HIV. She has not been on any new medications. No risk of drug hypersensitivity reaction
She does admit to a pretty much the description of Erythema Nodosum red painful round and elevated rash on her legs that comes and goes, low grade fever again common symptoms, dry mouth and dry eyes, palpitations, facial swelling rules out parotid gland swelling, palpitations, but admits to more common symptoms generalized weakness, being tiered all the time, and joint pain and swelling in her ankles this is diagnostic of sarcoidosis over the last two months.
Recent evaluation included a CBC with diff. LFTs except for elevated alkaline phosphataseindicate possible liver involvement, Immunoglobulinsrules out immune defeciency, CPKrules out myosistis, and UA rules out kidney involvementthat were all normal. Her ESR was elevated at 40common. Vitamin D was low at 10common . Her TB test was negativerules out TB. Her EKG was normalrules out cardiac involvement .
Her examination is remarkable Normal lung exam usually no findings on examfor tender round red and elevated skin lesions Erythema nodosum as well as swelling and tenderness in both anklesagain unique to sarcoid.
She had a HRCT this is on the work-up part of the article of chest revealed Hilar and Mediastinal adenopathystick with most common manifestation. There were mid to upper zone lung involvementagain unique to sarcoid. She underwent a biopsy again suggested in the work-up.
At this time you would recommend starting treatment with:These are listed in the treatment part and again you go with the recommended treatment regimen based on the history you put together.
- Glucocorticoids
- Methotrexateexplain why each answer is appropriate and why not based on what is said in the article.
- Plaquinel
- Azathioprine