A chest x-ray for sore ankles?

A young male patient presents with painful, inflamed ankles and is ordered a chest x-ray. He thinks maybe the doc didn’t quite hear him right.

But possibly his doctor is right on to what is happening and suspects Lofgren’s syndrome (named after Swedish Researcher Sven Lofgren 1910-1978).

This is a type of sub acute sarcoidosis which may present with erythema nodosum (tender red nodules), bilateral hilar adenopathy (enlarged lymph nodes on the border of the lungs), arthritis and fever.

The cause is unknown but environmental triggers have been implicated, combined with a genetic susceptibility. There is variable instances of this disease around the world but you may be more vulnerable if you are Irish, Scandinavian, African or Puerto Rican and less prone if Japanese. There has also been some association with those working in specific professions including health care workers, school teachers, agricultural workers exposed to agricultural dust, insecticides, pesticides and moulds, suppliers of building materials, hardware or gardening materials and firefighters.

Other risk factors are being female (85%), being young to middle age (mean age of disease is 35) and seasonal considerations, with the disease being more common in the spring in the Northern Hemisphere.

The patient may present with arthralgia, cough or shortness of breath, fever or malaise along with erythema nodosum (more likely if female) and bilateral ankle inflammation (more likely if male).

The diagnosis can be made with the assistance of a chest x-ray which will show mediastinal lymphadenopathy or pulmonary infiltration, lung function tests which may indicate decreased forced vital capacity, as well as elevated serum calcium and ACE levels. A lymph node biopsy may also confirm the diagnosis.

Generally the disease has a good prognosis and is usually benign and self limiting over a 6 month to 2 year period. Normal serum ACE levels at diagnosis and a particular HLA type (DRB1*03 positive as opposed to negative which points to a non resolving disease) are good prognostic markers

Management is supportive, with use of non steroidal anti inflammatories and short term bed rest. Occasionally corticosteroids will be given for severe symptoms such as severe arthritis.

Differential diagnoses may include infection, cellulitis, osteomyelitis, gout, polyarthritis, lymphoma, fungal infections, tuberculosis and bronchiogenic carcinoma to name a few.

But just remember that chest x-ray for anyone presenting with inflammatory ankle symptoms.

Irene