Dee Dimer, a 72 year old lady of Afrocarribean descent, has presented to her GP with her grandson. She has a four day history of swelling in the tip of her fingers. She has been feeling mostly "fine" otherwise. On further questioning she tells you she has been struggling with a 'flu' for a few months now and just feels a tickle at the back of her throat. This causes her to cough intermittently. She has a past medical history of a right knee swelling 2 months ago which now appears to have resolved. You also notice in her records that she has experienced recurrent conjunctivitis, first diagnosed a couple of years before she moved to UK.
You become suspicious of this vague history and perform a head to toe examination. You note her chest is clear and heart sounds are normal. Her abdomen is soft and non-tender, however you can feel the liver edge and become suspicious of hepatomegaly. On joint examination, you note mild swelling in her distal interphalangeal joints that are painful and reduced mobility. You also notice some erythematous lumps on her shins, which are tender to touch.
You send a set of bloods and note a raised ESR, raised calcium, normal LFT and normal serum ACE. An early immunology report also notes a normal anti-CCP and auto antibody screen is negative.
Over to you - what would you like?
Hand Xray shows punched out lesions of the distal phalanges and soft tissue swelling.
Chest Xray shows bilateral hilar lymphadenopathy
Noncaseous granulomas composed of a central core of histiocytes, epithelioid cells, and multinucleated giant cells
Now select your winner!
You picked:
Correct answer:Sarcoidosis
This lady presents with joint pain alongside normal Rh factor and anti-CCP. The erythematous lumps on her shin may be indicative of erythema nodosum. The chest X ray shows bilateral hilariously lymphadenopathy. The most common cause of this is sarcoidosis. Tuberculosis would also be a reasonable diagnosis to make here, however lack of night sweats and weight loss make this less likely.
