Respiratory for AMC MCQ

A 32 year old woman presents with fever, painful red nodules on her shins, and painful, swollen ankles. A chest radiograph shows bilateral hilar lymphadenopathy. She is otherwise well with a normal calcium. Her symptoms are self-limiting over a few weeks with simple analgesia. What is the most likely diagnosis?

1. Tuberculosis Swollen glands with weight loss and caseating granulomas, the key mimic. It does not fit swollen lung-root glands with red shin lumps and joint pains that clear on their own.
2. Hypersensitivity pneumonitis Lung inflammation from breathing in a trigger. But swollen lung-root glands with red shin lumps and joint pains that clear on their own does not point to it.
3. Sarcoidosis correct Correct. Swollen lung-root glands with red shin lumps, joint pains and fever is Lofgren syndrome, a form of sarcoidosis.
4. Berylliosis A granulomas-forming lung disease from a work exposure. That does not match swollen lung-root glands with red shin lumps and joint pains that clear on their own.
5. Metastatic malignancy Chest glands from a cancer that has spread. Here, swollen lung-root glands with red shin lumps and joint pains that clear on their own points elsewhere.

The point: Sarcoidosis is a disease where small lumps of inflammation (granulomas) form in many organs, and we do not know the cause. It is most common in young and middle-aged adults. The lungs are affected in most people, and the classic chest X-ray shows swollen glands at both lung roots (bilateral hilar lymphadenopathy), sometimes with lung shadows. Lofgren syndrome is a sudden form that often gets better on its own: swollen lung-root glands, red tender lumps on the shins (erythema nodosum), fever and joint pains. Other features are a red painful eye (uveitis), skin changes, and a high blood calcium because the granulomas turn on vitamin D. A blood test called serum ACE can be high but does not prove the diagnosis. Diagnosis needs the right picture plus granulomas without caseation on biopsy. The main mimic to rule out is tuberculosis. Many cases, especially Lofgren syndrome, clear up without treatment. Steroids are kept for disease that threatens an organ, such as bad lung, heart, brain or eye disease, or a high calcium causing symptoms. Heart and brain sarcoidosis are uncommon but are the dangerous forms.

Source: Therapeutic Guidelines (Australia) — Respiratory: sarcoidosis Therapeutic Guidelines (Australia) · tier 3, national formulary

A 32 year old woman presents with fever, painful red nodules on her shins, and painful, swollen ankles. A chest radiograph shows bilateral hilar lymphadenopathy. She is otherwise well with a normal calcium. Her symptoms are self-limiting over a few weeks with simple analgesia. What is the most appropriate next step in management?

1. Treat symptomatic hypercalcaemia Steroids, and avoid vitamin D and strong sun, when calcium is high. But swollen lung-root glands with red shin lumps and joint pains that clear on their own does not point to it.
2. Steroid-sparing agents for chronic disease Other drugs when long-term treatment is needed. It does not fit swollen lung-root glands with red shin lumps and joint pains that clear on their own.
3. Observation for self-limiting disease correct Correct. Lofgren syndrome usually clears on its own, so watching with simple pain relief is right.
4. Ophthalmology referral for uveitis Send eye disease to the eye specialist. Here, swollen lung-root glands with red shin lumps and joint pains that clear on their own points elsewhere.
5. Symptomatic treatment of erythema nodosum and arthralgia Simple pain relief for the shin lumps and joint pains. That does not match swollen lung-root glands with red shin lumps and joint pains that clear on their own.

The point: Sarcoidosis is a disease where small lumps of inflammation (granulomas) form in many organs, and we do not know the cause. It is most common in young and middle-aged adults. The lungs are affected in most people, and the classic chest X-ray shows swollen glands at both lung roots (bilateral hilar lymphadenopathy), sometimes with lung shadows. Lofgren syndrome is a sudden form that often gets better on its own: swollen lung-root glands, red tender lumps on the shins (erythema nodosum), fever and joint pains. Other features are a red painful eye (uveitis), skin changes, and a high blood calcium because the granulomas turn on vitamin D. A blood test called serum ACE can be high but does not prove the diagnosis. Diagnosis needs the right picture plus granulomas without caseation on biopsy. The main mimic to rule out is tuberculosis. Many cases, especially Lofgren syndrome, clear up without treatment. Steroids are kept for disease that threatens an organ, such as bad lung, heart, brain or eye disease, or a high calcium causing symptoms. Heart and brain sarcoidosis are uncommon but are the dangerous forms.

Source: Therapeutic Guidelines (Australia) — Respiratory: sarcoidosis Therapeutic Guidelines (Australia) · tier 3, national formulary

A 32 year old woman presents with fever, painful red nodules on her shins, and painful, swollen ankles. A chest radiograph shows bilateral hilar lymphadenopathy. She is otherwise well with a normal calcium. Her symptoms are self-limiting over a few weeks with simple analgesia. What is the most likely complication?

1. Hypercalcaemia and renal stones High calcium from vitamin D activation, causing kidney stones. It does not fit swollen lung-root glands with red shin lumps and joint pains that clear on their own.
2. Cardiac sarcoidosis Rhythm problems, heart block and sudden death. That does not match swollen lung-root glands with red shin lumps and joint pains that clear on their own.
3. Neurosarcoidosis Nerve problems, such as facial weakness. Here, swollen lung-root glands with red shin lumps and joint pains that clear on their own points elsewhere.
4. Steroid side effects Harm from long-term steroid treatment. But swollen lung-root glands with red shin lumps and joint pains that clear on their own does not point to it.
5. Pulmonary fibrosis correct Correct. Scarred lungs happen in long-standing disease, which this mild self-clearing form usually avoids.

The point: Sarcoidosis is a disease where small lumps of inflammation (granulomas) form in many organs, and we do not know the cause. It is most common in young and middle-aged adults. The lungs are affected in most people, and the classic chest X-ray shows swollen glands at both lung roots (bilateral hilar lymphadenopathy), sometimes with lung shadows. Lofgren syndrome is a sudden form that often gets better on its own: swollen lung-root glands, red tender lumps on the shins (erythema nodosum), fever and joint pains. Other features are a red painful eye (uveitis), skin changes, and a high blood calcium because the granulomas turn on vitamin D. A blood test called serum ACE can be high but does not prove the diagnosis. Diagnosis needs the right picture plus granulomas without caseation on biopsy. The main mimic to rule out is tuberculosis. Many cases, especially Lofgren syndrome, clear up without treatment. Steroids are kept for disease that threatens an organ, such as bad lung, heart, brain or eye disease, or a high calcium causing symptoms. Heart and brain sarcoidosis are uncommon but are the dangerous forms.

Source: Therapeutic Guidelines (Australia) — Respiratory: sarcoidosis Therapeutic Guidelines (Australia) · tier 3, national formulary