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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 6  |  Issue : 2  |  Page : 65-67

A Case of Pulmonary Sarcoidosis Misdiagnosed as Tuberculosis


Department of Chest and TB, Government Medical College Amritsar, Amritsar, Punjab, India

Date of Web Publication10-Jul-2018

Correspondence Address:
Srijna Rana
Government Medical College - Amritsar, Circular Road, Amritsar 143001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jacp.jacp_32_17

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  Abstract 

Sarcoidosis is a chronic inflammatory multisystem disease, most commonly involving the lungs, that usually affects middle-aged adults. Due to its clinicoradiological resemblance with tuberculosis (TB), in countries such as India, sarcoidosis is often misdiagnosed and mistreated as TB. We report a case of 62-year-old female with sarcoidosis, which was misdiagnosed as TB.

Keywords: Misdiagnosis, pulmonary sarcoidosis, tuberculosis


How to cite this article:
Rana S, Kaur R, Kajal NC, PS N. A Case of Pulmonary Sarcoidosis Misdiagnosed as Tuberculosis. J Assoc Chest Physicians 2018;6:65-7

How to cite this URL:
Rana S, Kaur R, Kajal NC, PS N. A Case of Pulmonary Sarcoidosis Misdiagnosed as Tuberculosis. J Assoc Chest Physicians [serial online] 2018 [cited 2018 Nov 16];6:65-7. Available from: http://www.jacpjournal.org/text.asp?2018/6/2/65/232964


  Introduction Top


Sarcoidosis is a chronic, multisystem inflammatory disease of unknown etiology characterized by the presence of noncaseating granulomas in different organs. Although the lungs are the most common sites of inflammation, sarcoidosis can involve other organs such as the eyes (intraocular and adnexal), skin, lymph nodes, salivary glands, heart, spleen, liver, and the nervous system.[1] A combination of clinical, radiological, and histological criteria is used to diagnose sarcoidosis. However, these criteria bear a similarity with tuberculosis (TB), thus posing a great challenge in countries endemic for TB. Mantoux test, high-resolution computed tomography, and transbronchial lymph node and lung biopsies are diagnostic modalities that play an important role in the diagnosis of sarcoidosis.


  Case Report Top


We present a case of a 62-year-old homemaker who presented to Chest and TB Hospital, Amritsar with a history of progressive breathlessness and dry cough since the past 6 months. She had been evaluated in the peripheral hospital and was started on treatment for TB under a national program for the past 5 months but with no improvement. Thereafter, she presented to the hospital with worsening of breathlessness since the past 2 weeks.

Her chest X-ray revealed bilateral hilar nodes with diffuse reticulonodular opacities (stage 4) [[Figure 1]a]. Mantoux test was negative. High resolution computed tomography (HRCT) revealed diffuse reticulonodular opacities [Figure 2] most prominent in the upper lobes with hilar and mediastinal lymphadenopathy consistent with interstitial lung disease. Echocardiography was normal. Blood investigations revealed a hemoglobin level of 11.9 g/dl, total leukocyte count of 9300/μl (with differential counts of neutrophils at 77%, lymphocytes at 23%, and eosinophils at 0%), erythrocyte sedimentation rate (ESR) of 47 mm, and random blood sugar (RBS) of 96 mg/dl. She had normal liver and renal function tests. Serological evidence for human immunodeficiency virus (HIV) infection was negative. On 6-minute walk test, a desaturation of 11% was seen initially.
Figure 1: (a) On admission, chest X-ray indicated bilateral hilar prominence with parenchymal involvement (stage 4). (b) Chest X-ray on follow-up after 2 months showing a clearing of the lesions

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Figure 2: High resolution computed tomography (HRCT) showing diffuse reticulonodular opacities

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Bronchoscopy was performed, and on cartridge based nucleic acid amplification test (CBNAAT) of bronchial aspirate, Mycobacterium tuberculosis was not detected, which indicated a possibility of some nontubercular pathology. Serum calcium levels were normal, but serum angiotensin converting enzyme levels were elevated at 131 u/l (6–60 u/l). Hence, a possibility of sarcoidosis was considered. Histopathology showed noncaseating granulomas consistent with sarcoidosis. On transbronchial needle aspiration, a granulomatous pathology was seen. In addition, on further transbronchial lung biopsy, noncaseating granuloma was seen [Figure 3]. She was started on oral prednisolone 20 mg/day for 4 weeks followed by slow tapering. She showed a significant improvement in her symptoms. Other systemic evaluation for sarcoidosis including the eyes was normal. Within 4 weeks of steroid treatment, lung functioning had improved [fev1 (97%), fvc (90% of expected)], and radiographic appearances showed improvement, with a significant resolution of parenchymal nodular infiltrates [[Figure 1]b].
Figure 3: Noncaseating granuloma on transbronchial lung biopsy

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  Discussion Top


Sarcoidosis is characterized by the formation of non-necrotizing epitheloid cell granulomas as a result of underlying immune dysregulation, typically showing multiorgan involvement, with the pulmonary involvement occurring in about 80–90% of the affected individuals.[2],[3] Sarcoidosis is prevalent globally and affects all age groups and ethnicities. The actual incidence of sarcoidosis in India is unknown, and the available data may be underestimated due to the lack of reliable epidemiological information from the subcontinent. Data from some studies indicate a wide variation in the prevalence rate of sarcoidosis ranging from 0.03 to 640 per 100,000 individuals.[4] There is a general perception among physicians that the prevalence of sarcoidosis has increased over the last two decades. This may be true, but could also be related to a better awareness of the condition, the availability of improved diagnostic facilities, and the increased ability of physicians to differentiate it from TB. Early diagnosis is vital to prevent irreversible damage to the lungs, particularly in treatment-responsive interstitial lung disease (ILD) such as sarcoidosis. However, currently, there is no “gold standard” diagnostic test for sarcoidosis.[5] The diagnosis of sarcoidosis is generally performed based on the evidence of compatible clinical and/or radiological pictures, along with the histopathological confirmation of noncaseating granulomas in tissue biopsy specimens. Furthermore, other diseases that manifest similar clinical or histopathological appearances need to be excluded before confirming sarcoidosis.[5]

TB and sarcoidosis are recognized as two similar disorders that share many clinical manifestations.[1] It is not uncommon for patients with sarcoidosis to be treated for TB before a correct diagnosis is made. Empirical antitubercular therapy is, however, not without risks and may result in drug toxicity including acute hepatic failure, apart from the cost of unneeded drugs. The constitutional symptoms of fever, malaise, weight loss, and fatigue can be observed for both diseases, TB and sarcoidosis. Additionally, respiratory symptoms are common to both conditions. Similar ocular manifestations such as dry eye and bilateral lacrimal gland enlargements can be seen in both sarcoidosis and TB. In the Indian context, the presence of serpiginous-like choroiditis is more likely to be associated with TB than with sarcoidosis.[6] Similarly, sarcoidosis always involved lung and mediastinal lymph nodes, showing noncaseous granulomas. Differentiating sarcoidosis from TB in countries with a high burden of the latter, therefore, requires a high index of clinical suspicion for both diseases, clinical acumen, and a detailed evaluation that should include a thorough evaluation of clinical, radiologic, and laboratory findings. Because of these reasons, sarcoidosis still is an underdiagnosed disease, although with increasing awareness, physicians are more vigilant for it. Due to a high prevalence of TB in India and also the resemblance in clinicoradiological features, sarcoidosis in India, thus, frequently gets treated as TB. However, this misdiagnosis should be avoided, because the treatments for these two diseases are definitely different.

In the endemic areas of these infections such as India, the burden of excluding is very high, given the very incidence and prevalence of TB. In India, GeneXpert, which uses the polymerase chain reaction (PCR) technology, is becoming more popular for analyzing sputum samples and other tissue samples for the diagnosis of TB. In a given clinical setting, a positive result by GeneXpert strongly favors a diagnosis of TB over sarcoidosis.[7]


  Conclusion Top


Diagnosing sarcoidosis in countries with high-TB burden does pose a significant challenge because of its resemblance to TB[8],[9] and the lack of facilities to perform invasive diagnostic tests. However, new cases of sarcoidosis are increasingly diagnosed in TB endemic areas in recent years due to increased awareness and the better availability of diagnostic modalities. In our case also, though initially we considered TB, but in view of hilar lymphadenopathy and strong epidemiologic history, progressive symptoms, negative bacteriological studies for TB, poor response to treatment, and predominant restrictive pulmonary function tests, we were prompted to investigate for other causes such as interstitial lung disease (primary and secondary). Bilateral hilar lymph node enlargement and symmetrical pulmonary infiltrates helped us in suspecting sarcoidosis as a cause of her pulmonary symptoms, which was later supported by elevated angiotensin-converting enzyme (ACE) levels and lung biopsy. Hence, the take-home message is that we should always reconsider the diagnosis if the response to treatment is not as expected.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Gupta D, Agarwal R, Aggarwal AN, Jindal SK. Sarcoidosis and tuberculosis: The same disease with different manifestations or similar manifestations of different disorders. Curr Opin Pulm Med 2012;18:506-16.  Back to cited text no. 1
    
2.
Zinck SE, Schwartz E, Berry GJ, Leung AN. CT of noninfectious granulomatous lung disease. Radiol Clin North Am 2001;39:1189-209.  Back to cited text no. 2
    
3.
Ma J, Zhu XH, Sun XW, Peng G. Analysis of CT features of pulmonary sarcoidosis. Chin J Radiol 2006;40:923-8.  Back to cited text no. 3
    
4.
Thomeer M, Demedts M, Wuyts W. Epidemiology of sarcoidosis. Eur Respir Mon 2005;32:13-22.  Back to cited text no. 4
    
5.
Sharma SS, Mohan A. Sarcoidosis in India: Not so rare! JIACM 2004;5:12-21.  Back to cited text no. 5
    
6.
Babu K. Sarcoidosis in tuberculosis-endemic regions: India. J Ophthalmic Inflamm Infect 2013;3:53-7.  Back to cited text no. 6
    
7.
Zhou Y, Li HP, Li QH, Zheng H, Zhang RX, Chen G et al. Differentiation of sarcoidosis from tuberculosis using real-time PCR assay for the detection and quantification of Mycobacterium tuberculosis. Sarcoidosis Vasc Diffuse Lung Dis 2008;25:93-9.  Back to cited text no. 7
    
8.
Guleria R, Mahashur A, Ghoshal AG, Thomas PK, Raghu G, Baughman RP. Challenges in diagnosing sarcoidosis in tuberculosis endemic regions: Clinical scenario in India. Sarcoidosis Vasc Diffuse Lung Dis 2016;33:381-4.  Back to cited text no. 8
    
9.
Gupta SK, Dutta SK. Diagnostic delay and difficulties in sarcoidosis in Eastern India. Lung India 1999;17:107-11.  Back to cited text no. 9
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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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