A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 31-year-old woman presents to the emergency department with a 2-week history of dry cough and shortness of breath on exertion. She says that she has also been feeling joint pain that has been increasing over time and is worst in the mornings. Finally, she has noticed painful swellings that have been appearing on her body over the last month. Her past medical history is significant for childhood asthma that does not require any current medications. She drinks socially and has smoked 2 packs per day since she was 16 years old. Physical exam reveals erythematous nodular lesions on her trunk and upper extremities. Serum protein electrophoresis shows polyclonal gammopathy. Which of the following would most likely also be seen in this patient?
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A
Acid-fast rodsIncorrect. Acid-fast rods on stain indicate Mycobacterium tuberculosis with CASEATING (necrotic) granulomas — sarcoidosis granulomas are noncaseating and TB doesn't typically present with erythema nodosum/polyclonal gammopathy.
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B
Antibodies to small nuclear ribonucleoproteinsIncorrect. Anti-snRNP antibodies are seen in mixed connective tissue disease and SLE (anti-Sm/anti-snRNP); not associated with the granulomatous lung-arthritis-erythema nodosum pattern.
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C
Golden-brown fusiform rodsIncorrect. Golden-brown fusiform 'ferruginous bodies' are asbestos fibers seen in asbestosis, which causes pleural plaques and interstitial fibrosis — not the multisystem inflammatory disease here.
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D
Noncaseating granulomasCorrect. sarcoidosis is defined by NONCASEATING granulomas in affected tissues (lung, lymph nodes, skin); Lofgren syndrome (erythema nodosum, hilar adenopathy, polyarthritis) is a classic acute presentation.
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E
Anti-cyclic citrullinated peptide antibodiesIncorrect. Anti-CCP antibodies are highly specific for rheumatoid arthritis, which causes symmetric small-joint synovitis and subcutaneous nodules but does not produce erythema nodosum, polyclonal gammopathy, or noncaseating granulomas on lung biopsy.
↑ Tap an answer to reveal the reasoning
Answer: D. A young woman with dry cough, exertional dyspnea, ARTHRALGIAS (worse in mornings), polyclonal hypergammaglobulinemia, and ERYTHEMA NODOSUM (painful erythematous nodules on the trunk/extremities) has SARCOIDOSIS. Lofgren syndrome — the acute presentation of sarcoidosis with the triad of erythema nodosum, hilar lymphadenopathy, and migratory polyarthritis (often ankles) — is highly characteristic and carries a favorable prognosis.
The pathologic hallmark is NONCASEATING GRANULOMAS in affected tissues (lung parenchyma, hilar lymph nodes, skin, eye, liver, heart). Granulomas are composed of epithelioid macrophages, giant cells (including Schaumann bodies, asteroid bodies), and surrounding T cells. Sarcoidosis disproportionately affects young African American women. Laboratory features include elevated ACE, hypercalcemia/hypercalciuria (from macrophage 1-alpha-hydroxylation of vitamin D), and polyclonal hypergammaglobulinemia from polyclonal B cell activation. Treatment of symptomatic sarcoidosis is systemic glucocorticoids; Lofgren syndrome often resolves spontaneously with NSAIDs for joint pain.
**Why each option:**
**A.** Acid-fast rods on stain indicate Mycobacterium tuberculosis with CASEATING (necrotic) granulomas — sarcoidosis granulomas are noncaseating and TB doesn't typically present with erythema nodosum/polyclonal gammopathy.
**B.** Anti-snRNP antibodies are seen in mixed connective tissue disease and SLE (anti-Sm/anti-snRNP); not associated with the granulomatous lung-arthritis-erythema nodosum pattern.
**C.** Golden-brown fusiform 'ferruginous bodies' are asbestos fibers seen in asbestosis, which causes pleural plaques and interstitial fibrosis — not the multisystem inflammatory disease here.
**D.** Correct: sarcoidosis is defined by NONCASEATING granulomas in affected tissues (lung, lymph nodes, skin); Lofgren syndrome (erythema nodosum, hilar adenopathy, polyarthritis) is a classic acute presentation.