A 39-year-old male, non-smoker, born in Peru, living in Spain in the last 8 years, with no medical history of interest presented two weeks before his admission in our service a painful swelling of the left dorsum.
The lesion did not improve with antibiotic treatment and antiarrhythmic drugs.
A week later, the patient developed the same symptoms in the right lower limb, adding a thermometered fever of up to 39oC.
On physical examination, the patient was afflicted with not being diagnosed with adenopathies. Pulmonary and cardiac auscultation were normal. No data of interest were observed on the abdomen.
The examination of the lower extremities revealed erythema and edema of undefined edge in the anterior and lateral face of both limbs to the knees, more evident in the left, painful to pressure and without joint inflammation.
Laboratory tests showed leukocytosis of 21,000 / ml with neutrophilia and lymphopenia, sedimentation rate: 67 mm / h, C-reactive protein: 24,48 mg / dl and acute phase.
Chest x-ray revealed a nodular lesion of 2.2 cm in diameter in the left hilium, suggestive of hiliar adenopathy.
Blood and urine samples were negative, serology for A, B and C viruses, borrelia cytomegalo agreement uro conorii, coxiella, Epvirus infection noncultive and acute data provided.
AFB and sputum cultures in usual media and Mantoux were negative.
A chest x-ray revealed mediastinal lymphadenopathies of significant size at the right paratracheal, pretracheal and perivascular levels, and hydatid disease.
Adjacent to the diaphragmatic dome and at the level of the basal segments of the LII, a pseudonodular image of about 2.2 cm in anteroposterior diameter of inflammatory aspect was observed, without ruling out other possibilities.
Both fissures were thickened with a small wedge of fluid on the right side.
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Fiberoptic bronchoscopy was performed with bronchoaspiration (BAS), bronchoalveolar lavage (BAL), bronchial and transbronchial biopsy.
The BAL revealed a predominantly lymphocytic cellularity with a CD4/CD8 ratio > 3.5 and bronchial and transbronchial biopsy revealed a mature respiratory epithelium, with isolated mucous glands in the lamina propria.
No granulomatous or suggestive elements of malignancy were found.
A mediastinoscopy was performed with biopsy of a right paratracheal lymphadenopathy that showed a lymph glangium occupied mostly by sarcoid-type granulomas, small and coalescent lymphocytic structures, with lymphocytic necrosis compatible with lymphocytic granuloma.
A skin sample was taken, whose histology showed an inflammatory nodule in subcutaneous cellular tissue consisting of histiocytes, some with epithelioid, polymorphonuclear, neutrophils and lymphocytes isolated, compatible with erythema nodosum.
Signaling and pulmonary diffusion were normal as well as the eye fundus.
The clinical findings and the biopsy compatible with sarcoid granuloma were established with corticoid treatment.
