Unilateral Dacryoadenitis and Contralateral Solitary Choroidal Granuloma as the Initial Presentation of Systemic Sarcoidosis: A Diagnostic Challenge

Purpose To report a rare case of unilateral dacryoadenitis and contralateral solitary choroidal granuloma as the initial presentation of systemic sarcoidosis, highlighting diagnostic challenges and treatment complications. Methods A 45-year-old male presenting with right-sided dacryoadenitis and a contralateral choroidal granuloma was evaluated. The diagnostic work-up included clinical examination, orbital and chest CT, SPECT-CT with gallium-67, biopsies of the lacrimal gland and mediastinal lymph nodes, serum ACE and lysozyme levels, and fundus imaging with EDI-OCT. The diagnosis of sarcoidosis was established based on WASOG and IWOS criteria. Treatment included corticosteroids, azathioprine, and adalimumab. Anti-tubercular therapy was subsequently added after a later diagnosis of tuberculosis during sarcoidosis treatment. Results At presentation, visual acuity was 20/200 in the right eye (OD) and 20/25 in the left eye (OS), with right-sided proptosis and photophobia. Orbital CT showed lacrimal gland enlargement; biopsy revealed lymphoplasmacytic infiltration without granulomas. EDI-OCT confirmed a solitary choroidal granuloma in the OS. Elevated ACE and lysozyme, bilateral hilar lymphadenopathy, and gallium-67 uptake supported the sarcoidosis diagnosis. Initial immunosuppressive therapy improved symptoms, but disseminated tuberculosis developed, requiring 14 months of anti-tubercular therapy. Conclusion This case highlights the diagnostic complexity of ocular sarcoidosis with inconclusive histopathology and underscores the diagnostic value of solitary choroidal granuloma. In tuberculosis-endemic regions, thorough infectious screening before immunosuppression and long-term multidisciplinary follow-up are essential to prevent serious complications.