An uncommon presentation of a common disease

A 24 year old woman presented to our institution with a two week history of multiple discrete, painful, nodular and indurated foci of erythema on her lower limbs against a six week background history of a constellation of more nonspecific symptoms including intermittent dry cough, malaise, migrating arthralgias, subjective fevers, anorexia and weight loss. She denied B symptoms. There were no ophthalmic, neurological or cardiovascular symptoms. Examination was significant for features of mild hyper-metabolism manifest by low grade pyrexia with accompanying diaphoresis in conjunction with bilateral lower limb predominant erythema nodosum. Laboratory studies revealed a neutrophilic leucocytosis, raised acute phase reactants/ inflammatory markers, normal serum calcium, ACE, Vitamin D, renal and liver indices. Chest radiography revealed bilateral hilar adenopathy with minimal interstitial involvement. A diagnosis of Löfgren's syndrome was suspected, an uncommon variant of multisystem sarcoidosis. Subsequent bronchoscopy with trans-bronchial tissue biopsy revealed non-caseating granulomas. The diagnosis was confirmed and treatment instituted with non-steroidal anti-inflammatory medication.