C40-19 Multiple Masqueraders: Development of Tuberculosis in a Patient With Sarcoidosis on Anti-TNF Therapy

Abstract Intro Multifocal lymphadenopathy and multisystem disease in a patient on immunosuppressing medications has a broad differential including infectious, malignant, autoimmune, and granulomatous diseases. Distinguishing these processes can be particularly challenging when radiographic and systemic symptoms are similar. Case A 32-year-old man with inflammatory arthritis on adalimumab and previously treated latent tuberculosis (TB) presented to pulmonary clinic with incidentally found pulmonary nodules that were incidentally found on CT imaging. A positron emission tomography (PET) scan showed hypermetabolic pulmonary nodules, mediastinal lymph nodes, splenic lesions, peritoneal lining and omentum. Omental biopsies revealed non-necrotizing granulomatous inflammation and negative acid-fast bacilli (AFB) smears, negative culture, and cytology. He was diagnosed with sarcoidosis, and the decision was made to pursue steroid sparing treatment with methotrexate and eventually infliximab was added to the regimen. After an initially good response to treatment, he developed cervical lymphadenopathy, night sweats, and subjective fevers two months after initiation of infliximab. Fine needle aspiration of the cervical lymph node identified granulomatous lymphadenitis with negative AFB and Grott methenamine silver (GMS) stains. An excisional biopsy of the cervical lymph node showed necrotizing granulomatous inflammation, while AFB and GMS stains were again negative, cultures eventually grew mycobacterium tuberculosis complex. He was treated for tuberculosis lymphadenitis with rifampin, and isoniazid in addition to vitamin B6 supplements and immunosuppression was held with improvement in his cervical swelling and constitutional symptoms. He has not shown evidence of recurrence of his sarcoidosis. Discussion Patients with sarcoidosis can have progressive and atypical disease courses, however, their disease and treatment can put them at risk of developing concomitant diseases. It is especially important to consider TB infections in patients who are on anti-tumor necrosis factor medications in combination with other immunosuppressing medications and despite previously ruling out a TB infection, patients can remain at risk for the development of active TB. This case highlights the need for a high index of suspicion for co-occurring disease processes in patients with sarcoidosis, and particularly tuberculosis infections which can have similar radiographic appearance and systemic symptoms. This abstract is funded by: None