A 35-year-old woman presents with bilateral hilar lymphadenopathy, erythema nodosum, and polyarthralgia of 3 weeks duration. Chest X-ray shows Paltauf's stage I sarcoidosis. Serum ACE is 82 U/L. She has no respiratory symptoms. Spirometry is normal. What is the most appropriate management?

• A Start prednisolone 40 mg/day immediately to prevent progression
• B Start hydroxychloroquine for skin and joint involvement
• C Perform transbronchial biopsy to confirm granuloma before any decision
• D Observe without treatment; Lofgren syndrome has a high rate of spontaneous remission ✓

Explanation

Lofgren syndrome is the acute presentation of sarcoidosis characterised by the triad of bilateral hilar lymphadenopathy, erythema nodosum, and acute polyarthritis — it is typically self-limiting and carries an excellent prognosis. Approximately 80–90% of patients with Lofgren syndrome achieve spontaneous remission within 2 years without treatment. NSAIDs can be used for symptomatic joint relief. Systemic corticosteroids are not indicated in the absence of respiratory compromise, significant hypercalcaemia, cardiac, neurological, or ocular involvement. Biopsy is also generally not required when the clinical picture is classic for Lofgren syndrome. Hydroxychloroquine has a role in cutaneous sarcoidosis but is not first-line for Lofgren syndrome.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.