Lauren is a 34-year-old receptionist who presents for review of a worsening facial rash.

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<p>Lauren is a 34-year-old receptionist who presents for review of a worsening facial rash.</p><p>She has previously been diagnosed with periorificial dermatitis and rosacea and has been taking oral tetracyclines for six weeks, with no effect.</p><p>She also reports intermittent non-productive cough and fatigue on and off for six months.</p><p>There is no associated fever, weight loss or night sweats.</p><p>Lauren is a lifelong Australian resident who has never travelled overseas.</p><p>On examination, the only finding of note is the rash (pictured), composed of papules that measure 1-10mm and are firm, non-scaly and red-brown.</p><p>Blood tests — including FBC, CRP and ESR — are normal.</p><p>A chest X-ray demonstrates bilateral hilar lymphadenopathy with disseminated lung nodules.</p><p>A skin biopsy shows non-caseating epithelioid granulomas with sparse peripheral lymphocytic infiltrates and no evidence of acid-fast bacilli on tissue staining.</p>

Dr Kate Kelso is a GP and medical editor at Australian Doctor.