IS IT SARCOIDOSIS OR TB?

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sarcoidosis and tuberculosis (TB) can have similar presentations. TB can present with localized pulmonary disease to widely disseminated infection. Military TB and Pott's disease are disseminated forms of TB that occur from lymphohematogenous spread. Sarcoidosis is a granulomatous disease that typically affects the lungs but can affect all organs. We present a case of a patient with back pain, pulmonary nodules, and bilateral hilar and mediastinal lymphadenopathy concerning for sarcoidosis who was found to have disseminated TB. CASE PRESENTATION: A 42-year-old male Congolese man with past medical history of fully treated abdominal TB presented with progressively worsening thoracic back pain and tachycardia. CT of the chest showed multiple enlarged mediastinal and bilateral hilar lymph nodes with bilateral upper lobe predominant pulmonary nodules in a perilymphatic distribution favoring sarcoidosis. Bronchoscopy and bronchioalveolar lavage demonstrated violaceous plaques throughout the right lung and biopsies were obtained. His back pain worsened oral steroid therapy was started. MRI of the thoracic and lumbar spine showed diffusely abnormal bone marrow signal, T10 and T11 vertebral body enhancement with adjacent large multiloculated peripherally enhancing mass, severe canal stenosis, cord flattening and cord signal abnormality. He underwent emergent T9-T11 laminectomy and epidural abscess evacuation. Cultures and biopsies showed acid-fast bacilli (AFB) and necrotizing granulomas. Therapy with rifampin, pyrazinamide ethambutol and isoniazid (RIPE) was started. Repeat CT of the chest showed innumerable pulmonary nodules with upper lung predominant distribution. He had no pulmonary symptoms. Sputum culture turned positive for AFB indicating pulmonary involvement. He improved and was discharged home with RIPE therapy. DISCUSSION: Sarcoidosis and TB have varying presentations, multisystem involvement, pulmonary nodules and granulomas, and radiographic findings of hilar and mediastinal lymphadenopathy. This case highlights the diagnostic challenges of differentiation between the two diseases while also demonstrating the pulmonary and extrapulmonary manifestations of TB. Sarcoidosis was initially suspected in this patient due to radiographic findings. He was treated with steroids, worsened and was then found to have disseminated TB. Treating the patient with steroids may have exacerbated the TB, suppressing his immune system and allowing for for dissemination of infection. Despite having radiographic and culture positive evidence of military TB, he did not have respiratory symptoms indicating advanced disease can be asymptomatic. CONCLUSIONS: Early differentiation between sarcoidosis and TB is crucial. Misdiagnosis of TB can result in dissemination of infection, skeletal deformity, paralysis, and multiorgan failure. Early treatment can prevent lymphohematogenous spread and improve outcomes. REFERENCE #1: Global tuberculosis report 2020. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO. REFERENCE #2: Sharma SK, Mohan A, Sharma A. Miliary tuberculosis: A new look at an old foe. J Clin Tuberc Other Mycobact Dis 2016; 3: 13-27. REFERENCE #3: Spagnolo P, Rossi G, Trisolini R, Sverzellati N, Baughman RP, Wells AU. Pulmonary sarcoidosis. Lancet Respir Med 2018; 6(5): 389-402. DISCLOSURES: no disclosure on file for Eric Bihler; No relevant relationships by Helene Rovnan, source=Web Response Speaker/Speaker's Bureau relationship with GlaxoSmithKline Please note: 10/1/21 - present Added 04/28/2021 by Meilin Young, source=Web Response, value=Paid speaker of speaker bureau