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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 42-44

A Case of Sarcoidosis Misdiagnosed as Tuberculosis


1 Assistant Professor, Department of TB & Chest, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna- 14, Bihar, India
2 Senior resident, Department of TB & Chest, Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna- 14, Bihar, India

Date of Web Publication11-Dec-2020

Correspondence Address:
Manish Shankar
Assistant Professor, Dept.of TB & Chest Disease, IGIMS, Sheikhpura, Patna 800014
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Sarcoidosis is a multisystemic chronic granulomatous disease of unknown origin, which can involve nearly all organs. In India tuberculosis is one of the common chronic infectious diseases presenting with high degree of morbidity and mortality. Almost any organ of the body can also be infected with tuberculosis. Both diseases have got high degree of similarity radiologically and histopathologically with the only difference being lack of caseation necrosis in sarcoidosis. We present here a case of sarcoidosis which were misdiagnosed as tuberculosis and treated with antituberculous drugs initially.

Keywords: Surcoidosis ; Tuberculosis


How to cite this article:
Shankar M, Kumar S, Tiwari MK. A Case of Sarcoidosis Misdiagnosed as Tuberculosis. J Indira Gandhi Inst Med Sci 2017;3:42-4

How to cite this URL:
Shankar M, Kumar S, Tiwari MK. A Case of Sarcoidosis Misdiagnosed as Tuberculosis. J Indira Gandhi Inst Med Sci [serial online] 2017 [cited 2021 Dec 7];3:42-4. Available from: http://www.jigims.co.in/text.asp?2017/3/2/42/303146




  Introduction: Top


Almost any organ can be affected by sarcoidosis but it most commonly affects the lung (90%), lymph nodes (75%), skin (25%) and eye (25%)[1]. The prevalence of systemic sarcoidosis is 1-40/100000, affecting mostly young adults between 20 and 40 years of age[2],[3].

More than 40% of the population is infected with tuberculosis (TB) in India and India accounts for one fourth of the global TB burden. TB can involve any part of the body but usually affects the lung. Similarly, sarcoidosis also involves lung and mediastinal lymph nodes, having non- caseous granulomas. For this reason, sarcoidosis sometimes can be misdiagnosed as tuberculosis. However, this misdiagnosis should be avoided as treatment of these two diseases are definitely different.

For the purpose of surveying the differences between sarcoidosis and tuberculosis, and improving the clinical differential diagnosis, this paper presents a case report of sarcoidosis which was misdiagnosed as tuberculosis.


  Case Report Top


A female patient aged 40 years presented to gastroenterology department in IGIMS, Patna with complain of abdominal pain, anorexia, dyspepsia, low grade fever, arthralgia for last 6 months. She had history of Diabetes Mellitus type 2 for last 10 years for which she was on oral hypoglycemic drugs with insulin. Her blood sugar was within normal range. She had no history of hypertension, antituberculous treatment (ATT), hyper or hypothyroidism. She was advised complete blood count, ESR, liver function test, renal function test, chest x-ray (postero anterior view), Ultrasound abdomen and upper gastro intestinal endoscopy which revealed prepyloric and pyloric ulcer. Multiple biopsy showed non specific inflammation. Her blood parameters were within normal range. Ultrasound abdomen showed enlarged periportal, pre mesenteric and mesenteric lymph nodes, largest 20x10mm with no caseation/calcification seen with borderline hepato-splenomegaly. Ultrasound guided fine needle aspiration cytology from lymph node showed clusters of epitheloid cells in the background of lymphoid cells with no evidence of caseation necrosis. Impression was made of tuberculous lymphadenitis and anti tuberculous therapy was started. Patient got no symptomatic improvement even after 9 months of antituberculous therapy. Repeat ultrasound abdomen after 9 months showed multiple mesenteric lymph nodes with no significant reduction in size along with hepato- splenomegaly. Antituberculous therapy was continued. Then patient consulted TB & Chest OPD. Chest X Ray was done which showed few tiny nodules in right lung. Contrast enhanced computed tomography abdomen [Figure 1]
Figure 1: CECT abdomen:showing liver enlarged 20cm, spleen enlarged 15 cm, both liver and spleen showed multiple small hypodense area studded all over hepaic & splenic parenchyma. Multiple enlarged lymph nodes involving peripancreatic, periportal, para-aortic, mesenteric and iliac area.

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was advised which showed liver enlarged 20cm,spleen enlarged 15 cm, both liver and spleen showed multiple small hypodense area studded all over hepatic & splenic parenchyma. Multiple enlarged lymph nodes were seen to involve peripancreatic, periportal, para-aortic, mesenteric, iliac & bilateral inguinal area. Impression was made of disseminated TB/Sarcoidosis. Computed tomography scan thorax [Figure 2]
Figure 2: CT scan Thorax: Showing multiple tiny nodules (<5mm) bilateral lung, no hilar nodes.

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was asked which showed multiple tiny nodules (<5mm) bilateral lung,no hilar nodes. Abdominal lymph node aspiration and its gene Xpert examination did not reveal mycsbacterium tuberculosis. Sputum Gene Xpert did not show MTB. Sputum for fungal smear was negative. Mantoux test showed negative result. Spirometry showed restrictive changes. Her bronchoscopy was done. Tracheobronchial tree and mucosa were normal. Broncheoalveolar lavage (BAL) was taken and sent for cartridge based nucleic acid amplification test, culture/sensitivity, fungal smear and malignant cytology examinations which all were negative. Bronchoalveolar lavage CD4, CD8 count could not be done due to unavailability of these tests in IGIMS. Transbronchial lung biopsy was done. Result showed interstitial fibrosis and granulomatous inflammation without caseation necrosis consistent with sarcoidosis. Serum angiotensin converting enzyme (ACE) was significantly elevated i.e. 121 U/L. Serum Calcium was 9.7mg/dl. In the meanwhile patient developed maculopapular rash over trunk, photophobia and lacrimation and uveitis. A clinical impression of sarcoidosis was made and patient was started on prednisolone 40mg which was gradually tapered down and stopped after 18months. Patient improved symptomatically. Follow up ultrasound abdomen showed marked resolution in size of abdominal lymph nodes, splenic and liver lesions resolved, hepatic and splenic size became normal. Maculopapular rash and uveitis resolved.


  Discussion Top


Although there is no universal criteria for the diagnosis of sarcoidosis, disease is suspected when a patient presents with signs or symptoms consistent with sarcoidosis and has granulomas on tissue biopsy. Most patients with sarcoidosis have pulmonary and lymph glands involvement which may either be asymptomatic or may cause dry cough ,dyspnea, or chest discomfort but the disease may also involve extrapulmonary sites such as gastrointestinal system, eye, skin, central nervous system etc. as in our case as it presented predominantly with extrapulmonary i.e gastrointestinal symptoms along with skin and eye symptoms. Laboratory testing may show an increased angiotensin-converting enzyme (ACE) level; although, this test has insufficient specificity to make a diagnosis of sarcoidosis. Examination of bronchoalveolar lavage fluid(BAL) also helps in the diagnosis, as markedly increased ratio of CD4+ T cells to CD8+ T cells in the BAL fluid is relatively specific for sarcoidosis; but, diagnosis is generally confirmed by showing epithelioid granulomas on transbronchial biopsy.[4],[5],[6],[7] Other manifestation of sarcoidosis are maculopapular rash,uveitis, arthralgia and arthritis, enlarged and tendor lymph nodes, hoarse voice, pain in hand,feet or other bony areas, kidney stone formation, enlarged liver, development of arrhythmia, pericarditis, or heart failure. nervous system involvement including hearing loss, seizure, psychiatric disorders (for example, dementia, depression, psychosis). Other causes of granulomatous disease also should be excluded example including mycobacterial infections such as tuberculosis and leprosy, syphilis, granulomatosis with polyangiitis, fungal infections such as coccidiomycosis and histoplasmosis, and exposures to particulates such as beryllium.

Steroids are important in the treatment of sarcoidosis. Nevertheless, the exact time point of treatment, dosage, and benefits versus side effects are still controversial[8],[9].


  Conclusion Top


In summary,we report a case of systemic sarcoidosis with pulmonary and extrapulmonary involvement of the gastrointestinal system, skin and eye which clinical and radiographic presentation is very similar to tuberculosis. We should be very cautious in the treatment of any granulomatous lesion which does not improve after effective dose of antitubercuolous therapy, keeping sarcoidosis as one of the differential diagnosis.



 
  References Top

1.
Sharma OP. Sarcoidosis: clinical, laboratory, and immunologic aspects. Semin Roentgenol. 1985;20:340-5.  Back to cited text no. 1
    
2.
James DG. Epidemiology of sarcoidosis. Sarcoidosis. 1992;9:79-87.  Back to cited text no. 2
    
3.
Newman LS, Rose CS, Maier LA. Sarcoidosis. N Engl J Med. 1997;336:1224-34.  Back to cited text no. 3
    
4.
Statement on sarcoidosis. Joint Statement of the American Thoracic Society (ATS), the European Respiratory Society (ERS) and the World Association of Sarcoidosis and Other Granulomatous Disorders (WASOG) adopted by the ATS Board of Directors and by the ERS Executive Committee, February 1999. Am J Respir Crit Care Med. 1999;160:736-55.  Back to cited text no. 4
    
5.
Costabel U. CD4/CD8 ratios in bronchoalveolar lavage fluid: of value for diagnosing sarcoidosis? Eur Respir J. 1997;10:2699- 700.  Back to cited text no. 5
    
6.
Jing yu,Jing wang,Ruiping zhu,Jianlin wu. A case report of atypical sarcoidosis misdiagnosed as tuberculosis. Radiology of infectious diseases,2016;3:40-3.  Back to cited text no. 6
    
7.
Deepak A. Rao, Paul F. Dellaripa, Extrapulmonary Manifestations of Sarcoidosis;Rheum Dis Clin North Am. 2013 : 277-97.  Back to cited text no. 7
    
8.
Kennedy PT, Zakaria N, Modawi SB, Papadopoulou AM, Murray-Lyon I, du Bois RM, Jervoise N Andreyev H, Devlin J. Natural history of hepatic sarcoidosis and its response to treatment. Eur J Gastroenterol Hepatol. 2006;18:721-6  Back to cited text no. 8
    
9.
Baughman RP, Lower EE. Therapy for extrapulmonary  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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