Clinical Images

Dyspnea and a Rash

Figure 1. CT chest demonstrating bilateral hilar and paratracheal lymphadenopathy

Figure 2. Pretibial lesions consistent with erythema nodosum

Authors: Fabiola Rios de Choudens, MD, Carlos Pla Fernandez, MD 

A 42-year-old Caucasian male presented to the ER with complaints of intermittent chest pain radiating to back, dyspnea on exertion, and presyncope.  He reported that a month prior to presentation, he had a combination of low-grade fevers, fatigue, painful “shin rash”, and diffuse polyarticular joint pain worst over his ankles. CT angiogram of the chest done to rule out pulmonary embolism revealed significant bilateral hilar and paratracheal lymphadenopathy (Figure 1) and a few bilateral peripheral nodules measuring up to 6mm. On physical exam, his “shin rash” (Figure 2), was tender to palpation and consistent with erythema nodosum.

MCQ: A patient presents with painful tibial lesions and ankle pain for the past 1-2 weeks. Chest x-ray reveals perihilar adenopathy. What is the best next step in diagnosis?

a.    No further diagnostic testing required

b.    Biopsy of tibial lesions

c.    Bronchoscopy and biopsy of perihilar lymphadenopathy

d.    Serum CRP, ESR, ACE levels

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Fabiola Rios de Choudens, MD: Internal Medicine resident at University of South Florida in Tampa. Originally from Puerto Rico, she studied in the University of Puerto Rico Medical school and is interested in medical education and providing learning opportunities for students and residents.

Carlos Pla Fernandez, MD: Internal Medicine resident at University of South Florida in Tampa. Interested in Endocrinology and general Internal Medicine with particular interest in medical education.