Case Study: Inflammatory Disease Presenting as a Doughnut Sign

CASE PRESENTATION

A 37-year-old woman with a remote history of uveitis presented to the emergency department with bilateral ankle and left wrist pain and swelling. The swelling had progressed during the past 3 to 4 weeks. Her medical history included obesity and gastroesophageal reflux disease.

The patient’s exam was notable for erythema nodosum, bilateral ankle synovitis, and wrist synovitis. Serologically, her erythrocyte sedimentation rate was 53 mm/hour and C-reactive protein was 63.17 mg/dL. Her rheumatoid factor, antinuclear antibody, and cyclic citrullinated peptide antibody and complements and dsDNA were normal. An infectious disease workup was negative for Lyme disease, gonorrhea and chlamydia.

The patient’s posterioanterior and lateral chest x-ray was read as normal. However, given the high clinical suspicion for Lofgren syndrome (based on the lower extremity polyarthritis and erythema nodosum), a second radiology opinion was sought.

Careful inspection of the lateral view of her chest x-ray revealed an increased density in the infrahilar region. Based on this finding, a computed tomography scan of her lungs was performed that revealed bulky bilateral perihilar lymphadenopathy with scattered subcentimeric pulmonary nodules in a perihilar distribution. Subsequently, an end-bronchial lymph node biopsy revealed noncaseating granulomatosis lymphadenitis.

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