Sarcoidosis Presenting as L？fgren’s Syndrome with Myopathy

A 34-year-old female patient, who had proximal muscle weakness for 8 months, presented with erythema nodosum lesions on the pretibial region in addition to pain, swelling, and movement restriction in both ankles for the last one month. Thoracic CT demonstrated hilar and mediastinal lymphadenopathy. She underwent mediastinoscopic lymph node biopsy; biopsy result was consistent with noncaseating granuloma. Serum angiotensin converting enzyme level and muscle enzymes have been elevated. Muscular MRI and EMG findings were consistent with myositis. Muscle biopsy was done, and myopathy was found. The patient was diagnosed with sarcoidosis, L？fgren's syndrome, and sarcoid myopathy. The patient displayed remarkable clinical and radiological regression after 6-month corticosteroid and MTX therapy. 1. Introduction Sarcoidosis is a systemic granulomatous disease of unknown origin and can involve many tissues and organs in the body. The disease most commonly presents with bilateral hilar lymphadenopathy, lung infiltrations, and skin and ophthalmic lesions [1]. L？fgren’s syndrome (LS) is an acute sarcoidosis presentation characterized by arthritis/arthralgia, erythema nodosum (EN), and bilateral hilar lymphadenopathy [2]. Musculoskeletal system involvement may usually be in the form of synovitis of the large joints of lower extremities. Sarcoidosis may involve proximal muscles and may mimic idiopathic inflammatory myositis [3]. Symptomatic muscular disease is rare and seen in 0.5–5% of the cases [4]. It has three different types: chronic myopathy, palpable nodules, and acute myositis [5]. In the present case, we have reported the presence of chronic sarcoid myopathy together with L？fgren’s syndrome. 2. Case Report A 34-year-old female patient consulted with several physicians for proximal muscle weakness, which had continued and worsened for 8 months. Her complaints became worse despite NSAIDs and she presented to our outpatient clinic of rheumatology because of pain, swelling, and restricted motion in both ankles, as well as painful erythematous lesions on the pretibial region, which started a month ago. On the inspection, erythema nodosum skin lesions were detected on the pretibial region (Figure 1). Musculoskeletal system examination revealed synovitis in both ankles and proximal muscle weakness in the proximal extremities. Results of laboratory analysis were as follows; SGOT: 152？U/L (normal 0–30？U/L), SGPT: 144？U/L (normal 0–40？U/L), alkaline phosphatase: 46？U/L (normal < 90？U/L), LDH: 318？U/L (normal 135–220？U/L), CK: 1213？U/L (normal 26–192？U/L), C-reactive