A Duel Between Two Great Masqueraders: Sarcoidosis and TB

Abstract

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. QuantiferonÔ 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.