Case Presentation:

A 41–year–old African–American woman traveling in Ghana experienced progressive edema, diffuse joint pain and night sweats over a 9–day period. Three days before her presentation she noted dyspnea, dry cough and inability to walk due to knee pain. As a result of her declining health, she returned home prematurely. Prior to travel, she was administered all recommended immunizations, including yellow fever and polio. She received 2 weeks of malaria prophylaxis with mefloquin, but her luggage was stolen, and she was unable to continue the medication. She noted multiple mosquito bites during her visit. The patient additionally reported having a new sexual partner while abroad, but she had no vaginal discharge or dysuria. On exam, pulse was 110 beats per minute, and temperature was 40.6°C. The left sclera was injected, there was no adenopathy and lungs were clear. The wrists, ankles and left knee were warm with decreased range of motion, and there was a left knee effusion. Erythematous nodular lesions were present on both anterior lower legs. Laboratory evaluation revealed thrombocytosis, c–reactive protein of 223 mg/L, and negative smears for malaria. Chest x–ray showed hilar adenopathy and clear lung fields. The patient was treated for septic arthritis while awaiting results from arthrocentesis, skin and lung biopsies.

Discussion:

This woman’s misfortunate trip to Ghana suggests an extensive differential of infectious and inflammatory conditions. Gonococcemia, histoplasmosis, acute HIV, tuberculosis, malaria, chikungunya disease and dengue fever might all present similarly. However, during a brief hospitalization the patient had no culture evidence for infection and had a skin biopsy confirming erythema nodosum. Transbronchial lung biopsies demonstrated noncaseating granulomas. She had the classic triad of Löfgren’s syndrome. Löfgren’s is an acute variant of sarcoidosis typified by the presence of hilar adenopathy, erythema nodosum, and arthritis. Treatment is conservative with non–steroidal anti–inflammatory medication and occasionally steroids for persistent symptoms. There is no consensus on the etiology of sarcoidosis, but speculation for an infectious etiology exists. This leaves us to ponder whether this patient had an exposure to a causative agent in Ghana or was destined to become ill regardless of travel.

Conclusions:

This case highlights the importance of obtaining under–emphasized historical details such as travel, immunization and sexual histories. These features helped construct a complete differential diagnosis. However, if a judicious evaluation was not followed, a more protracted and costly hospital course would likely have resulted. Following this process led to the diagnosis of Löfgren’s. The importance of recognizing this sarcoidosis variant is that it carries an excellent prognosis. This patient had complete resolution of symptoms at a 4–month follow up visit.