|Year : 2021 | Volume
| Issue : 3 | Page : 341-343
Co-existence of pulmonary tuberculosis with sarcoidosis
Harveen Kaur, Dilbag Singh, Naveen Pandhi
Department of Pulmonary Medicine, Government Medical College, Amritsar, Punjab, India
|Date of Submission||05-Aug-2021|
|Date of Acceptance||30-Aug-2021|
|Date of Web Publication||03-Sep-2021|
Department of Pulmonary Medicine, Government Medical College, Amritsar, Punjab
Source of Support: None, Conflict of Interest: None
Tuberculosis (TB) and sarcoidosis are multisystem, chronic granulomatous diseases. Although characterized by similar clinical manifestations, these disease entities vary significantly in etiologies and management. Sarcoidosis is an immunological disorder of unknown etiology, characterized by the presence of noncaseating granulomas in the tissues involved. TB is the infectious disease caused by Mycobacterium tuberculosis, characterized by granulomas with caseous necrosis. It is rare to have both the diseases concomitantly. We present the case of a 38-year-old male with microbiological confirmation of coexistent pulmonary TB and sarcoidosis.
Keywords: Bronchoalveolar lavage, fiberoptic bronchoscopy, noncontrast computed tomography chest, sarcoidosis, tuberculosis
|How to cite this article:|
Kaur H, Singh D, Pandhi N. Co-existence of pulmonary tuberculosis with sarcoidosis. Int J Mycobacteriol 2021;10:341-3
| Introduction|| |
Sarcoidosis is a multisystem disease, characterized by noncaseating granulomas. It has an overall mortality ranging from 1% to 5%, usually resultant from respiratory or cardiac manifestations.
Both sarcoidosis and tuberculosis (TB) are characterized by typical epithelioid cell granulomas, and thus, it is hypothesized that sarcoidosis is a separate manifestation of infection by mycobacterium. It is very rare to have sarcoidosis coexistent with TB, although TB may develop as an opportunistic infection in sarcoidosis patients following steroid therapy.
The diagnosis becomes challenging in the cases with simultaneous occurrence of sarcoidosis and TB, as treatment for both these conditions widely differs. TB is treated primarily with anti-tuberculous therapy (ATT) and steroids are added only on specific indications while the management of sarcoidosis is mainly with steroids and immunosuppressive agents.
The initiation of corticosteroid therapy in patients with underlying infection, adds onto the life-threatening complications. Thus, it is important to do proper evaluation, including case-history data. Whenever there arises a dilemma in the diagnosis between sarcoidosis and TB, corticosteroid therapy should be advanced till the microbiological confirmation is obtained.
The presented case is unique and diagnostically challenging for the very rare co-existence of lung sarcoidosis with pulmonary TB in a 38-year-old male, with noncaseating lung granulomas, but finally, the patient recovered well on dual therapy.
| Case Report|| |
A 38-year-old male presented with chief complaints of breathlessness, chronic dry cough, and low-grade fever, with evening rise of the temperature for the past 3 weeks. There was no history of paroxysmal nocturnal dyspnea, bronchial asthma, rash, photosensitivity, and oral ulcers. He had no previous history of TB. There was no history of any other chronic illness.
On admission, he had tachycardia and tachypnea. Examination revealed pallor but no clubbing, icterus, edema, cyanosis, or peripheral lymphadenopathy. On auscultation, he had bilateral vesicular breath sounds with coarse crepitations in interscapular and bilateral infrascapular areas. All other systemic examination was normal.
Initial laboratory evaluation revealed: hemoglobin 10.4 g/dL, erythrocyte sedimentation rate 40 (normal range 0–15 mm/h), white blood cells 10,020/mm, C-reactive protein 11.9 mg/L, aspartate aminotransferase 82 U/l, alanine aminotransferase 70 U/l, alkaline phosphatase 66 U/l, serum angiotensin-converting enzyme levels were 124 U/l (normal 0–56), and serum calcium levels were 12.2 mg/dL (normal 8–10 mg/dL). He had normal blood urea and serum creatinine levels. Mantoux test was negative.
Chest X-ray [Figure 1] showed bilateral hilar lymphadenopathy along with segmental area of consolidation in the right upper zone with multiple, bilateral, small pulmonary nodules. Noncontrast computed tomography of the chest [Figure 2] revealed multiple enlarged lymph nodes in prevascular, right paratracheal, pretracheal, precarinal, subcarinal, and bilateral hilar region, with largest measuring 35 mm × 25 mm in size, with small calcific specks. Segmental areas of collapse consolidation in the right upper lobe with nodular alveolar infiltrates in the surrounding lung parenchyma, with bilateral patchy areas of ground-glass opacities with septal thickening.
|Figure 1: Chest X-ray PA view showing bilateral hilar lymphadenopathy with segmental area of collapse consolidation in right upper zone|
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|Figure 2: Noncontrast computed tomography chest showed extensive mediastinal and bilateral hilar lymphadenopathy with nodular alveolar infiltrates in the surrounding lung parenchyma with multiple small pulmonary nodules and bilateral patchy areas of ground glass opacities with septal thickening. Mild left pleural effusion and pericardial effusion|
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Fiber-optic bronchoscopy with bronchoalveolar lavage was performed. It revealed the edema and hyperemia of bronchi on both sides, along with secretions seen in right upper lobe bronchus. Bronchial aspirate revealed lymphocytic alveolitis 64% of the total, with a CD4/CD8 ratio of 4.2. Bronchial aspirate tested negative for acid-fast bacilli on routine smear microscopic examination by Ziehl–Neelsen staining. The histopathological evaluation of the bronchial wall biopsy [Figure 3] was performed. It showed noncaseating, chronic granulomatous reaction, indicating pulmonary sarcoidosis. Based on these findings, the diagnosis of lung sarcoidosis was established, and he was started on prednisolone 1 mg/kg body weight.
|Figure 3: Histopathological findings of bronchial wall biopsy showed chronic noncaseating, subpleural granuloma, characteristic of sarcoidosis. (Hematoxylin and eosin stain, Magnification ×20)|
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Two weeks after the corticosteroid introduction for pulmonary sarcoidosis, the culture of bronchial aspirate for Mycobacterium tuberculosis was found to be positive. Thereafter, he was initiated on ATT for 6 months. Within 2 weeks of starting ATT, the patient improved clinically with reduced breathlessness and reduction in chest crepitations.
| Discussion|| |
TB and sarcoidosis are chronic granulomatous diseases affecting the lungs and other organs. Sarcoidosis, a multisystem disease, involves the lungs frequently and results into pulmonary fibrosis. It is an antigen-driven immune disorder and a causal role of mycobacterial antigens has been hypothesized. There exists an overlap in the classic manifestations of TB and sarcoidosis, which makes the definitive diagnosis difficult without a microbiological confirmation. Patients can present with a wide range of symptoms. The hallmark, noncaseating epitheloid cell granulomas can affect most organs, including the skin.
TB and sarcoidosis mimic each other clinically. The concomitant presence of both these chronic granulomatous conditions poses diagnostic challenge and is referred to as tuberculous sarcoidosis, which shows three patterns (1) patients with TB who develop sarcoidosis subsequently, (2) patients with coexistent TB and sarcoidosis; and (3) patients with chronic sarcoidosis who develop TB, as a result of therapy-related immunosuppression.
Chest X-ray usually shows hilar and mediastinal lymphadenopathy. Computed tomography of the chest is effective and accurate for the evaluation of mediastinal diseases, including sarcoidosis. The typical findings include bilateral hilar lymphadenopathy in 80%–90% of patients, alveolar nodules, and at a later stage, pulmonary fibrosis.
Both sarcoidosis and TB are granulomatous disorders; the granulomas in sarcoidosis are noncaseating, whereas TB is characterized by caseating granulomas. Histopathological features are usually insufficient for establishing the diagnosis of sarcoidosis, especially in TB endemic areas. It is difficult to distinguish sarcoidosis from TB, when caseous necrosis is not present and acid-fast staining is negative in the biopsy specimen of patient.
This case was diagnosed with co-existence of pulmonary TB and sarcoidosis based on the clinical, laboratory, imaging, and histopathological findings. In the cases where rapid deterioration occurs in patient's clinical condition, corticosteroids and ATT should be started concomitantly till the microbiological confirmation is attained.
| Conclusion|| |
The co-existence of sarcoidosis and TB is rare and a highly under-recognized entity. There is a significant overlap in the clinical presentation of TB and sarcoidosis, which sometimes poses diagnostic difficulty. It is advisable in situations of dilemma to advance the corticosteroid therapy till the microbiological confirmation of TB is established.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that his name and initial will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]