'Broken Ankles' Associated with Insidious Dry Cough: Lofgren's Syndrome

Abstract

35-year-old male with no history presented after initial workup for dry cough associated with swollen, painful right ankle pain and difficulty ambulating.Patient reports insidious onset of dry cough for 3 months. Several weeks later, he noticed bilateral ankle pain associated with lower extremity myalgias that were so severe it "hurt to walk". He denied history of gout, arthritis or trauma. Initially reports alleviation of joint pain with Aleve only to eventually return weeks later. Joint pain returned in his left wrist and right ankle, though admits to re-involvement of the left ankle to a lesser extent. Of note, his right ankle swelling was now associated with edema and erythema.Patient presented to ED two weeks before current hospitalization, undergoing xrays of right foot which revealed mild soft tissue swelling along the lateral malleolus but with no evidence of fracture. Initial concern for DVT, so D-dimer elevated to 1.63. CTA chest revealed mediastinal and bilateral hilar lymphadenopathy and patchy opacities in right lower lobe consistent with pneumonia. Because of this, patient received Z-pak plus 10-day course of prednisone and was discharged home. Reported improvement in joint pain, swelling and diminished cough, however with incomplete resolution of symptoms.After completion of steroid course, he experienced recrudescence of symptoms and now including night sweats. He reported his "joint pain is much worse," feeling like he was walking around "on broken glass" and expressing difficulty "walking to the bathroom without getting covered in sweat". Initially admitted to outside hospital and broad autoimmune workup was initiated. CRP 7.22 and ESR 37. Large immunological battery otherwise negative. CT chest revealed persistent consolidation in postero-inferior right lower lobe and unchanged adenopathy vs imaging 2 weeks prior. Started on IV Rocephin for persistent RLL pneumonia, but given bilateral mediastinal adenopathy, was transferred to Mercy for rheumatology consult as well as bronchoscopy-guided biopsy of adenopathy. Ultimately, diagnosis was made on history without biopsy, patient was discharged on tapered prednisone course after uncomplicated hospitalization.Sarcoidosis is a multisystem granulomatous disease with predilection for the lung. Usually insidious in onset with slow disease progression. Typically presents in younger patients with bilateral hilar lymphadenopathy, migratory polyarthralgia, erythema nodosum and fevers. Diagnosis can be made clinically alone, without being biopsy-proven. Treatment typically involves use of NSAIDs and supportive measures with spontaneous resolution occurring in 1-2 years. However, as noted in our patient with more severe symptomatology, glucocorticoid taper may be warranted.