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

July 16, 2014
Mohenish Singh, DO

Brandon Hill, MD

James Mcdonald, MD

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?

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