Pulmonary Sarcoidosis Vs Tuberculosis

Introduction:Fifty percent of sarcoid cases have clinically silent
Sarcoidosis with a prevalence of 10/100,000, is ainvolvement of organs, which is one of the
multisystem disease of unknown etiologyhallmarks.¹ 20-40% of symptomatic patients
characterized by non-caseating granulomas.i Ithave respiratory symtoms and 10-40% have eye
involves virtually any organ, lungs, thoracic lymphpain, rashes arthralgia and other symptoms while
nodes, skin liver, central nervous system, eyes,20-30% with constitutional symptoms like weight loss
kidneys and heart, and is more common inand fatigue.¹
Afro-Americans. There is no sex predilection butSarcoidosis may present atypically as Lofgrens and
some manifestations of the disease are moreHeerFordts syndrome.¹ Sarcoidosis in younger
common is females. ² It begins in the third orpatients with spontaneous remission and less than
fourth decade and tends to be rare in children andtwo years duration of symptoms are classified as
the elderly.? We are presenting a case of sarcoidosissubacute while chronic form have more than two
of the lungs which should be considered in theyears duration with insidious onset and presents with
differential diagnosis of tuberculosis, common inconstitutional symptoms, pulmonary fibrosis and
countries like Pakistan.nephrocalcinosis.¹
Discussion:In one study in which histopathological diagnosis
Considering the common disease first which isrequired presence of non-caseating granuloma,
tuberculosis, long-standing history of low grade fever,bronchoscopic biopsy yielded diagnosis in 60% of
weight loss and persistent cough not responding topatients with stage I disease, tranbronchial needle
anitibiotics along with raised ESR and positive PPD(13aspiration yielded diagnosis in 53% and two
mm) supports tuberculosis put PPD is not reliable inprocedures in combination yielded 83% of diagnosis.
developing countries as a tool for diagnosis.7,8 In stage II disease probability of obtaining a
Diagnostic procedure performed was anpositive result with a single specimen was 46%, the
endobronchial biopsy. ² Histopathologicalyielded with more specimens followed a logarithmic
examination showed multiple granulomas, composedcurve and increased to 90% with four specimen, at
of epitheloid histiocytes, with occasional Langerhanswhich point the yield approached a plateau for
giant cell and no necrosis. According to one studyadditional specimen. 7,8 The suggests that four
endobronchial biopsy increased the yield of fibreopticbiopsy specimens are sufficient to make diagnosis.
bronchoscopy by 20.6%.4 Fungal stain, AFB stainsBiopsy of gastrocnemius muscle is another sensitive
and cultures, were negative (Table II).and specific tool for diagnosis. 9 If transbronchial
The patient had X-ray findings consistent with stagebiopsies are non-diagnostic, mediastinal lymph node
II disease. 1,5 Unilateral hilar adenopathy is an atypicalbiopsies are diagnostic in 8-90% of case. 10 Finally ,
manifestation of sarcoidosis in initial stage. 6 Her ACEthe patient was kept on steroids (Deltacortil) 40mg
level was raised about three folds, serum calcium wasday in divided doses and He/She responded well with
in upper normal range and ESR was persistentlyremarkable improvements. 11 His/Her ESR came
raised (Table I) supported by radiological findings,down to 13mm, chest X-ray showed remarkable
which favour sarcoidosis. PPD is negative inimprovement as infiltrates and bilateral hilar
sarcoidosis are anergic to PPD tuberculin butadenopathy disappeared altogether.
distribution of memory T-cells in the blood andWe kept His/Her on the same dose of Deltacortil till
humoral immune response are normal and8 weeks, and then it was trapered off to 7.5mg/day
opportunistic infections are rare.¹without recurrence.