PAINFUL RASH. K. Kamjoo 1 ; 1 University of California, Los Angeles, Sylmar, CA (Tracking ID #76685) LEARNING OBJECTIVES: 1-To recognize the clinical presentation of sarcoidosis and Lo È fgren's syndrome. 2-To understand that sarcoid is a systemic disease with multi-organ involvement and 3-To discuss treatment modalities for sarcoid and sarcoid arthritis. CASE INFORMATION: A 24 year old male without significant past medical history presented to Emergency Department (ED) with complaint of painful rash over both legs for 2±3 weeks. Patient is an Argentinean exchange student who traveled to the US approx. six months prior to this presentation. Patient was seen at an outside clinic for the same complaint and was treated with Keflex and Ibuprofen without improvement. Patient reported that few days after appearance of rash; both of his ankles became swollen and painful. Although patient reported that walking was very painful, he denied any weakness or limitation of movement. In addition to the rash, patient admitted that he has been having night sweats and subjective fevers for the past couple of weeks. Patient also reported a slight dry cough. Initial vitals in ED were: temp of 38.2, blood pressure of 132/70, pulse of 95, and respiratory rate of 16. On physical exam patient appeared alert but in mild distress due to leg pain. Heart exam was regular sinus without any murmurs and lungs were clear to auscultation bilaterally. Abdomen was benign. Examination of skin revealed large nodules that were raised, red and tender to touch. Nodules were warm to touch and distributed randomly all over both legs. Both ankles had non-pitting edema but they had full range of motion. Ankles were tender to touch and passive range of motion was painful. Initial lab results showed a serum calcium level of 9.4 and a sedimentation rate of 47. Chest x-ray examination revealed bilateral hilar lymphadenopathy and EKG showed a normal sinus rhythm without any conduction abnormalities. Patient was subsequently admitted to hospital and placed in respiratory isolation. Patient had negative coccidiomycosis titers and ruled out for pulmonary Tuberculosis. HIV test was also negative. Patient remained clinically stable but continued to have a low-grade fever. CT scan of chest showed bilateral hilar and sub-carinal lymphadenopathy as well as multiple 1 cm nodules within lung fields. Subsequently, patient had bronchoscopy with biopsy and pathology report confirmed presence of non-caseating granulomatous lesions. Patient was started on 40 mg of prednisone per day and made a remarkable recovery. IMPLICATIONS/DISCUSSION: Sarcoidosis is a multi-system disorder of unknown cause characterized by a non-caseating granulomatous reaction in affected organs. Lo È fgren's syndrome is a variant of sarcoidosis in which acute sarcoidosis often presents with constitutional symptoms, polyarthritis, and erythema nodosum. The diagnosis of sarcoidosis should be based on a tissue biopsy, but a patient with typical Lo È fgren's syndrome may not need biopsy proof. Non-steroidal anti-inflammatory agents usually effectively alleviate sarcoid arthritis and joint symptoms associated with erythema nodosum. In severe acute arthritis and in chronic arthritis, corticosteroids may be required to control the symptoms. with a productive cough of white sputum and intermittent fevers, chills and night sweats for 1 month. She also complained of dizziness, weakness, a decreased appetite and a 5 pound weight loss over 4 weeks. She had been treated with antibiotics for 14 days which provided no relief. She denied visual changes, head pain, neck stiffness, chest pain, shortness of breath, dyspnea on exertion, nausea, vomiting, dysphagia, abdominal pain, diarrhea, urgency, dysuria, arthralgias or myalgias. Her medications included hydrochlorothiazide (HCTZ) and lisinopril. On physical exam, she appeared cachectic with dry mucous membranes and decreased skin turgor. Temperature was 38.4. Lung exam was clear bilaterally. Cardiac exam revealed a II/VI systolic murmur. There was no lymphadenopathy or skin rash. Abdominal exam revealed no masses or tenderness. She was hydrated and her HCTZ was held. She had multiple episodes of fever of up to 39.1. At the end of 7 days, her diagnostic testing revealed the following: normal CBC with differential; normal LFT's; 6 blood and 2 urine cultures were negative; Legionella antigen was negative; non-reactive PPD and a TSH of 2.6. Chest x-ray revealed biapical pleural thickening. ESR was 85. ANA, Rheumatoid factor (RF) and Anti-ds DNA were negative. Transthoracic echocardiogram (TTE) was negative for vegetation. Chest and abdominal CT scans revealed no significant findings. Bone marrow biopsy, aspirate and culture were negative. Bilateral temporal artery biopsies revealed severe temporal arteritis (TA). She was discharged on prednisone and her symptoms resolved after 1 week of therapy. IMPLICATIONS/DISCUSSION: FUO is defined as a temperature greater than 38.3 on several occasions for more than 3 weeks or after 1 week of thorough diagnostic testing performed in the out-or inpatient setting. Earlier studies reported that infections represented 41% of all cases. Collagen vascular diseases represented 30% and tumors represented 13%. Miscellaneous causes represented 2% and in 13% of cases the etiology was not identified. More recent studies reveal that infections are less common than multisystem disease and this trend was even more pronounced in patients over 70 years of age. A cost-effect approach in the elderly consists of confirmation of fever and a thorough history and physical exam. Laboratory analysis should consist of a CBC with differential, ESR, TSH, chemistry and liver panel, urine analysis and multiple blood and urine cultures. HIV, EBV, CMV, ANA and RF should be considered in certain cases. Stop all nonessential drugs. Imagining should include a TTE, chest and abdominal CT scans. A temporal artery biopsy should be considered if the ESR is more than 40 mm/hr, even in the absence of symptoms. Gallium scan for hidden abscesses and liver and bone marrow biopsies should be considered only in certain cases. Explorative laparotomy is a final resort. LEARNING OBJECTIVES: Introduction: Typhoid fever is a common disease in the developing countries.