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Endgames Case Review

Just a painful swelling of the ankles?

BMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k436 (Published 09 March 2018) Cite this as: BMJ 2018;360:k436

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Re: Just a painful swelling of the ankles?

The authors report a classical presentation of probable acute sarcoidosis in a young man with arthralgia (with ankle involvement), erythema nodosum and bilateral hilar lymphadenopathy. These features were present on initial examination and chest radiography. I agree with the authors' comment that invasive diagnostic tests are usually not needed. One wonders therefore why they then felt it necessary to request a PET computed tomography scan (which confirmed the radiologically obvious hilar lymphadenopathy), ankle ultrasound (which showed the clinically evident oedema) and invasive bronchoalveolar lavage (with results compatible with acute sarcoidosis)? The BMJ is in the forefront of the fight against excessive over-investigation, and I suggest that the correct course here was to accept the provisional diagnosis of acute sarcoidosis and only proceed to further investigation if the disease progressed or failed to resolve with symptomatic treatment.

Competing interests: No competing interests

12 March 2018
Charles D Shee
Retired pulmonary physician
Kent