A Duel Between Two Great Masqueraders: Sarcoidosis and TB

Abstract

SESSION TITLE: Lung Infections 2 SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Monday, October 30, 2017 at 11:00 AM - 12:00 PM INTRODUCTION: Tuberculosis (TB) and sarcoidosis are granulomatous diseases that challenge clinicians. We report a patient whose unusual presentation exemplified such a diagnostic dilemma. CASE PRESENTATION: A 26-year-old Pakistani female at 38 weeks gestation presented with transient right-sided weakness, aphasia and 2 weeks of headache. She was afebrile and appeared well. The fetus was in no distress. She experienced a brief recurrence of neurologic symptoms the next day. Examination was normal except during the episode. CTA was negative for stroke. Brain MRI (Fig.) showed bilateral ring-like lesions consistent with inflammation or infection. Lung apices included in the CTA revealed bilateral nodular infiltrates. Recent CXR was clear. Chest CT (Fig.) revealed adenopathy and lung nodules. On repeated questioning, the patient denied respiratory symptoms. Routine laboratory evaluation was unremarkable. LP yielded 455 WBCs with 78% lymphocytes; glucose 26; protein 121; low ADA. CSF AFB smear was negative. Vasculitis serology and HIV test were negative. Quantiferon™ was previously positive. Bronchoscopic lung biopsy and placental tissue showed noncaseating granulomas with negative AFB stain. BAL smear was negative for AFB. The healthy appearance of the patient and fetus, lack of pulmonary symptoms, absence of fever, low ADA, presence of noncaseating granulomas, rarity of placental TB and immunocompetence all favored sarcoidosis over TB. Nevertheless, given her demographics, anti-TB therapy was initiated. Ultimately, BAL and lung biopsy cultures returned positive for M. tuberculosis. CSF AFB culture was negative. DISCUSSION: Our case illustrates the overlap between TB and sarcoidosis and how the two conditions can compete for a diagnosis. Because the treatment approaches are so different, an erroneous decision can be devastating. Systemic granulomatosis in a well-appearing immunocompetent patient favors sarcoidosis but disseminated TB cannot be discounted. Pregnancy may have been the immunomodulatory condition that predisposed our patient to dissemination. Likewise, it’s important to keep in mind that TB meningitis can present nonspecifically and mimic sarcoidosis or vasculitis. CONCLUSIONS: Disseminated TB is a life-threatening great imitator, requiring a high index of suspicion even when the preponderance of the evidence suggests an alternate diagnosis. Reference #1: Daan Fritz, Diederik van de Beek et al; Clinical features, treatment and outcome in neurosarcoidosis: systematic review and meta-analysis. BMC Neurol. 2016; 16: 220 DISCLOSURE: The following authors have nothing to disclose: Hussein Assallum, Irfanali Kugasia, Dipak Chandy, Oleg Epelbaum No Product/Research Disclosure Information