Sarcoidosis accompanied by pulmonary tuberculosis and complicated by sacroiliitis

Abstract

We report the unique occurrence of a unilateral sacroiliitis in a patient with active sarcoidosis accompanied by pulmonary tuberculosis. Convincing (clinical) evidence of sarcoidosis as the extremely rare cause of this articular involvement is presented. Discussion is focused on comparison of sarcoidosis and tuberculosis, particularly with respect to their articular involvement, and the literature of previously reported cases of sarcoid sacroiliitis is briefly reviewed.The granulomatous diseases of sarcoidosis and tuberculosis can both lead to arthritis (1-7). Since both disorders may occur simultaneously (8), an apparent articular involvement can cause confusion. In tuberculosis, the vertebral column, including the sacroiliac (SI) joints, is involved relatively frequently (1,2); such involvement is very rare in sarcoidosis (3-7).To our knowledge, this report describes the first patient with sarcoidosis accompanied by pulmonary tuberculosis with concomitant evidence of a complicating sarcoid sacroiliitis. CASE REPORTIn January 1990, a 34-year-old Moroccan man presented in our emergency unit with severe asthma provoked by a recent upper respiratory tract infection. His family history suggested a familial tendency for this asthma. His medical history was otherwise unremarkable. Physical examination revealed no further abnormalities.The chest radiograph revealed a bilateral hilar and right-sided paratracheal polycyclic lymphadenopathy with a diffuse reticulonodular pattern in both upper lung fields ( Figure 1A). Laboratory investigations showed an erythrocyte sedimentation rate (ESR) of 16 mm/hour (Westergren), and normal values on hematologic, serum creatinine, and liver function tests. The angiotensin-converting enzyme (ACE) level was 58.7 unitsfliter (normal 16-51). The tuberculin skin reaction was 0 x 0 mm. Sputum showed no acid-fast bacilli (AFB) on Ziehl-Neelsen (ZN) stain, and cultures for (myco)bacteria were negative. Pulmonary function data were normal (Table 1). A fiberoptic bronchoscopy revealed no visible abnormalities, but peripheral transbronchial biopsies from the right upper lobe revealed tissue with noncaseating epithelioid cell granulomas without AFB ; cultures for (myco)bacteria were also negative.A diagnosis of sarcoidosis was made, and the condition was managed accordingly. His asthma responded well to a short course of oral prednisolone, followed by a regimen of inhaled bronchodilators and corticosteroids.He presented in March 1991 because of a 3-month history of slowly progressive, exerciseinduced fatigue and dyspnea. Results of the physical examination were unremarkable. The ESR and ACE values were unchanged. Radiographically, the upper lung fields showed alveolar shadowing. Pulmonary function data had worsened ( Table 1). Fiberoptic

Rheumatologic Manifestations of Sarcoidosis

“…19 Noncaseating granulomas have been seen on biopsy of the sacroiliac joint, which supports an etiologic role of sarcoidosis in sacroiliitis in patients with both conditions. 20 However, sacroiliitis may present in the context of other rheumatologic conditions, such as reactive arthritis, ankylosing spondylitis, and psoriatic spondyloarthropathy, which may coexist with sarcoidosis, and these conditions should therefore be ruled out patients with sarcoid and sacroiliitis findings. 19 Typically, the back pain of sacroiliitis can be managed with physiotherapy and analgesia.…”

A Case of Sacroiliitis Developing After Löfgren’s Syndrome

“…[5] In 1951, Verstraeten and Bekaert [6] reported the first case of a patient with both sacroiliitis and sarcoidosis. In the case reported by Griep et al, [13] sacroiliitis was unilateral. Pulmonary tuberculosis had been diagnosed before the occurrence of sacroiliitis and was treated by antituberculous triple therapy in these cases.…”

“…[19] Sacroiliitis has been described in Whipple's disease and tuberculosis. [13] In conclusion, sacroiliitis should be suspected in patients with sarcoidosis who have persistent hip pain, and the necessary investigations should be performed for sacroiliitis.…”

Sacroiliitis mimics: a case report and review of the literature

“…There are rare reports of sarcoidosis coexisting with spondyloarthropathy [ 36 , 42 , 43 ]. Biopsy of the SI joint in sarcoid cases demonstrates non-caseating granulomata in the synovium [ 44 , 45 ]; however, non-specific inflammatory changes have been described [ 39 ]. Even with biopsy changes consistent with sarcoid, tuberculous infection must be ruled out as well.…”