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Internal Medicine

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A 22-year-old sexually active woman who came to New York City two days ago from Puerto Rico is seen for bilateral ankle arthritis and nodules on the legs.

Her illness began two weeks ago with migratory pain involving both knees symmetrically which spontaneously resolved. She then developed bilateral ankle pain and swelling, which has persisted.

On exam, she has tender reddish-purple nodules over the anterior lower legs and clear evidence of bilateral ankle arthritis with effusions. Her CBC is normal. Chest x-ray shows hilar adenopathy.


Which one of the following is the most likely diagnosis?

  • Rheumatic fever

  • Dengue

  • Gonococcemia

  • Sarcoidosis


N G
H S

This patient has migratory arthritis which might make one think of disseminated gonorrhea since you are given gratuitous information about her sexual history. The key to this question is the hilar adenopathy and the skin lesions which are nodules rather than the petechial or pustular lesions typical of disseminated gonorrhea. Gonococcemia may be accompanied by arthritis which is not symmetrical and not associated with hilar adenopathy or erythema nodosum.

Lofgren’s Syndrome, a form of sarcoidosis, is characterized by the triad of hilar adenopathy, erythema nodosum and arthritis, typically of the lower extremities.

Rheumatic fever causes a migratory polyarthritis following streptococcal pharyngitis but is not associated with hilar adenopathy.

Dengue viral infection causes joint pain (and is sometimes called “break-bone fever” for that reason) and is endemic to Puerto Rico but does not cause erythema nodosum or hilar adenopathy.

Primary tuberculosis can cause hilar adenopathy without pulmonary infiltrate and erythema nodosum but not the bilateral arthritis seen here.

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