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

July 15, 2014

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?

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?

Click here to see the complete case report and discussion.