ACCP-SEEK Board Review Question of the Month |

A 42-Year-Old Policeman With Rash and Abnormal Chest Radiograph* FREE TO VIEW

George A. Sarosi
Author and Funding Information

*From the ACCP-SEEK program, reprinted with permission. Items are selected by Department Editors Richard S. Irwin, MD, FCCP, and John G. Weg, MD, Master FCCP. For additional information, phone 1-847-498-1400.

Correspondence to: George A. Sarosi, MD, FCCP, Roudebush VA Medical Center, Medical Service (111), 1481 West 10th St, Indianapolis, IN 46202-32803

Chest. 2003;124(5):2014-2016. doi:10.1378/chest.124.5.2014
Text Size: A A A
Published online

A 42-year-old policeman is seen in the dermatology clinic because of a sudden onset of a rash over both legs and on the extensor surfaces of both forearms. It is accompanied by redness and tenderness over both ankles for the past 5 days. About 2 weeks earlier, he had complained of a few days of unproductive cough, which he described as “close to a cold.” The patient was recently discharged from the Army after 20 years of service in the military police. During his enlistment, he had lived in many states, including Arkansas, California, Illinois, and Wisconsin.

The patient was referred to you because of an abnormal chest radiograph (Fig 1 ). Physical examination is normal except for the presence of a rash over both legs and arms (Fig 2 ). Both ankles are tender to palpation, but there is no redness or swelling. The differential diagnosis includes all of the following, except:

  • A. Sarcoidosis

  • B. Blastomycosis

  • C. Actinomycosis

  • D. Histoplasmosis

  • E. Coccidioidomycosis

Answer: C. Actinomycosis

The patient has Löfgren syndrome: bilateral hilar adenopathy, erythema nodosum, and arthralgias of the ankles. (The only component of the fully expressed syndrome that is missing is uveitis.) The constellation of findings in our patient is most frequently seen with sarcoidosis; however, similar findings are seen in histoplasmosis, coccidioidomycosis, and blastomycosis. This syndrome is not seen in actinomycosis, making option C the correct choice.

The onset of erythema nodosum, the patient’s skin lesions, is a dramatic occurrence, which inevitably brings the patient to medical attention, with or without associated findings. When uveitis is also present, sarcoidosis is the most likely diagnosis. When uveitis is absent, however, all the endemic mycoses enter into the differential diagnosis. These lesions are common in coccidioidomycosis (referred to as desert rheumatism and the bumps) and in histoplasmosis, where the sudden appearance of these lesions frequently leads to recognition of a community-wide Histoplasma outbreak. It is much less frequent in blastomycosis, but it has also been associated with outbreaks. Differentiation between sarcoidosis and endemic mycoses becomes potentially important if glucocorticosteroid therapy is contemplated. Measurement of angiotensin-converting enzyme is not helpful; it may be negative in patients with established sarcoidosis, and it may be elevated in the various acute fungal illnesses.

Figure Jump LinkFigure 2. Lesions of erythema nodosum on hand.Grahic Jump Location
Mañá, J, Gómez-Vaquero, C, Montero, A, et al (1999) Löfgren’s syndrome revisited: a study of 186 patients.Am J Med107,240-245. [CrossRef] [PubMed]



Mañá, J, Gómez-Vaquero, C, Montero, A, et al (1999) Löfgren’s syndrome revisited: a study of 186 patients.Am J Med107,240-245. [CrossRef] [PubMed]
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
Case 2-2016. N Engl J Med 2016;374(3):264-74.
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543