A 35-year-old immunocompetent HIV-negative man presents with fever, bilateral hilar lymphadenopathy, erythema nodosum, uveitis, and arthralgia. Serum ACE is elevated. BAL shows CD4:CD8 ratio >3.5. Transbronchial biopsy reveals non-caseating granulomas. Which statement about treatment is most accurate per current guidelines?
- A Prednisolone 40 mg/day for 6 months — all symptomatic sarcoidosis requires treatment
- B This presentation (Löfgren syndrome) typically resolves spontaneously; observation with NSAIDs for arthralgia is appropriate ✓
- C Hydroxychloroquine is the first-line agent for pulmonary sarcoidosis
- D Infliximab is first-line for this presentation
Explanation
Löfgren syndrome (erythema nodosum + bilateral hilar lymphadenopathy + periarticular ankle inflammation) is an acute presentation of sarcoidosis carrying an excellent prognosis with spontaneous remission in >85% of cases within 2 years, particularly in HLA-DRB1*03-positive Caucasians. Systemic corticosteroids are not indicated for Löfgren syndrome; NSAIDs manage arthralgias symptomatically. Corticosteroids are reserved for progressive pulmonary disease, cardiac sarcoidosis, neurosarcoidosis, hypercalcemia, or ocular involvement not responding to topical therapy. Hydroxychloroquine is used for skin/mucosal sarcoidosis. Infliximab is reserved for refractory multi-organ disease.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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