The clinical conundrum of diagnosing and treating systemic sarcoidosis in a high TB burden area

A 53-year-old woman from Southern India presented with weight loss, anorexia, fever and asthenia. Whole body positron emission tomography/computed tomography (PET-CT) showed fluorodeoxyglucose-avid mediastinal and abdominal lymphadenopathy with hepatic, splenic, parotid and lacrimal glandular inflammations. Endoscopic ultrasound-guided fine needle aspiration of subcarinal lymph node showed non-caseating granulomas. Initial serum ACE level was elevated but with normal calcium. Despite the suspicion of sarcoidosis, a trial of antituberculosis therapy was started empirically due to similar presentations of disseminated tuberculosis (TB) in this high endemic area. The patient subsequently deteriorated and was admitted with symptomatic hypercalcaemia. Her subsequent ACE levels were very high, supportive of a diagnosis of systemic sarcoidosis. She was given steroid pulse therapy, and 5 months later had fully recovered. This case highlights the challenges faced by physicians in high TB-endemic areas when managing granulomatous diseases as they are concerned about missing TB, the difficulties in diagnosing sarcoidosis and the role of pulse steroid therapy.