Brandon Hill, MD

A 33-year-old patient is referred to you a few weeks after [[{"type":"media","view_mode":"media_crop","fid":"25807","attributes":{"alt":"Lofgren syndrome","class":"media-image media-image-right","id":"media_crop_2193795721654","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2422","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"","typeof":"foaf:Image"}}]]presenting to the emergency department with frontotemporal headache, nausea and vomiting, ankle pain with swelling, fevers, and lower-extremity rash. Prednisone treatment resolved the ankle symptoms but not the headaches and fevers.

New-onset chest and abdominal pain followed, and the headaches worsened. She was admitted to the hospital for presumed meningitis. Elevated high-sensitivity C-reactive protein was detected, but other tests ruled out infectious mononucleosis and syphilis as well as meningitis.

Your examination adds the following to the diagnostic picture: new-onset right periorbital edema, erythema, and photophobia. You find her negative for antinuclear antibodies, angiotensin-converting enzyme (ACE), cryoglobulin, and vasculitis. However, she had positive Lyme titers and a CT scan of the chest revealed pulmonary nodules.

What condition do you suspect?

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Her headaches haven't improved with prednisone. It's not meningitis. Your tests show negative for vasculitis but positive for Lyme. Can you guess the diagnosis?

Headache, Rash, Then Lung Nodules: What Is It?

The woman with this rash has been revisiting the clinic with a variety of symptoms: Initially chronic headache, nausea and vomiting, ankle pain and swelling and then, a few days ago, this rash. [[{"type":"media","view_mode":"media_crop","fid":"23576","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_9509536864961","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1899","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"margin: 5px; float: right;","title":" ","typeof":"foaf:Image"}}]]

The biopsy revealed superficial perivascular dermatitis. Prednisone was initated, presuming an autoimmune disorder, but she returned a few days later with worsened headache, now exacerbated by chest pains and abdominal pain.

Serology has ruled out a large number of infectious possibilities, and the patient has made her way to the rheumatology department. She now reports continued low-grade fevers and arthralgia, but rheumatologists also observe new-onset right periorbital edema and erythema, and the patient now exhibits photophobia.

The patient is plagued by problems: Severe headaches, nausea, vomiting, a rash, chest and abdominal pains, and by the time she reaches a rheumatologist, periorbital edema and photophobia. Can you guess the cause?

Author | Brandon Hill, MD

Articles

Headache, Rash, Then Lung Nodules: What Is It?

Young Woman With Fever, Rash, Joint Pain, and Photophobia