- Tubercular sarcoidosis occurs when a patient has both tuberculosis (TB) and sarcoidosis. - TB and sarcoidosis are granulomatous diseases that can affect multiple organ systems. - There are many clinical, radiological, and pathological similarities and differences between the two diseases that are important to distinguish between them. Key diagnostic tests include looking for acid-fast bacilli, checking for caseating granulomas with necrosis, and tuberculin skin testing. - Proper diagnosis is important because the treatment approaches for sarcoidosis versus TB are different. Sarcoidosis often responds well to steroids while TB requires anti-tubercular

1. Dr. Zia Hashim
M.D. (Internal Medicine), D.M. (Pulmonary & CriticalCare), FCCP
Associate Professor
Department of Pulmonary Medicine
Sanjay Gandhi Postgraduate Institute of Medical Sciences
Lucknow

2.  Tuberculosis and sarcoidosis are both
granulomatous diseases which affect
multiple systems
 Tubercular sarcoid:When both of them
coexist in the same patient

3.  TB bacilli are inhaled
 Engulfed by Alveolar Macrophages but cannot
digest
 Macrophages lose motility accumulate at the
site of injury. More cells are recruited (T cells)
 Small area of fibrous cuffing occurs and infection
is contained
 Disease: If there is change in immunity:
granuloma caseates and rupture
 Airway
 Blood stream

10.  Poorly degraded antigen
 Infectious antigens
 ? Mycobacterium tuberculosis: strong contender
 Non infectious
 Pollens
 Insecticides

11.  25% of sarcoidosis tissues have evidence of
mycobacterial DNA that is 15-fold greater
than in nonsarcoidosis control tissues
 Copies of mycobacteria DNA in tissue from
sarcoidosis patients are
 1000-fold less than in the tissues of patients
infected with Mycobacterium tuberculosis

12. CONSTITUTIONAL SYMPTOMS
 Fever
 Malaise
 Anorexia
 Weight loss
 Fatigue
RESPIRATORY SYMPTOMS
 Cough
 Dyspnea
 Chest pain

13. SARCOIDOSIS PATIENTS
“WALK IN”
TUBERCULOSIS PATIENTS
“BROUGHT IN”

14. TUBERCULOSIS
 Asymptomatic: Unlikely
 Expectoration
 Hemoptysis
 Patient is usually sick
 If constitutional symptoms
are more tuberculosis is
more likely
SARCOIDOSIS
 May remain asymptomatic
 Fatigue is characteristic

15. TUBERCULOSIS
 Any age
 Any sex
 Low immunity
 Low socioeconomic status
SARCOIDOSIS
 20-40 years
 F: M 2:1

16.  Lofgren’s syndrome
 Heerfordt’s syndrome
 Lupus pernio
 Sjogren like syndrome
 Facial nerve palsy: unilateral or bilateral

18.  Fever
 Parotid gland
enlargement
 Uveitis
 Xerostomia
 Facial nerve palsy:
unilateral or bilateral

19.  Characterized by
destructive lesions
Involvement of
 Nose
 Alae nasi
 Cheek
 Nasolabial folds

20.  Granulomatous uveitis
(Most common ocular
manifestation)
 Conjunctival granuloma
 Episcleritis
 Lacrimal gland
involvement (Dry eyes)

21.  Cervical lymphadenopathy
 Pleural and pericardial effusion
 Ascites
 Ileocaecal tuberculosis: Intestinal obstruction
 Tubercular meningitis

22.  Tuberculosis: Present
 Sarcoidosis: Absent

23.  Lacrimal and parotid: Sarcoidosis
 Adrenal gland:Tuberculosis
 Myocardial involvement, Heart block:
Sarcoidosis

24. POSTTB OBSTRUCTIVE DS
CHRONIC END STAGE
SARCOIDOSIS

25.  If positive diagnosis of tuberculosis likely
but sarcoidosis is very unlikely
 But if negative compatible clinical picture is
required to exclude tuberculosis with
confidence

26. CECT is required for characterization
 Sarcoidosis: Symmetrical
 Tuberculosis: Asymmetrical

27.  Symmetric hilar and
mediastinal
lymphadenopathy;
without or with
characterstic pulmonary
changes
 Uniform enhancement
 Discrete
 No central necrosis

30.  Low attenuation or typical rim
enhancement with central necrosis
 Associated lung changes/ pleural effusion
 Often asymmetrical
 Heterogeneous

32. BRONCHIOLE
ARTERY
VEIN & LYMPHATICS

33. BRONCHIOLE
ARTERY
VEIN & LYMPHATICS

34. CENTRILOBULAR
NODULES
PERILYMPHATIC
NODULES

38.  Random:
 Touch pleura
 Not related to any
structure
 Centrilobular: Away
from pleura in the centre
of lobule
 Perilymphatic:
 Touch pleura
 Along vessels, bronchi

45.  Endobronchial tuberculosis:
 BAL is usually helpful
▪ AFB smear
▪ AFB culture
▪ GeneXpert MTB/RIF
 Endobronchial sarcoidosis

46. nonspecific
bronchitis
edema / hyperemia
actively caseating
ulcerative tumourous
granular
fibrostenosis

47.  Mucosal granularity
 Cobble stone
appearance
 Always perform EBB
form nodules if seen

48.  TBLB has good yield in
sarcoidosis because
pathology is
peribronchovascular
 TBLB can be combined
with EBB
 Yield is better if both
are combined

49.  Central necrosis
 Aspiration of pus
 Heterogeneous
echogenecity

50.  Homogenous or
heterogenous
 Heterogenous pattern:
 Echogenic pattern of lymph
node is not uniform
 Multiple small low echoic
areas
Homogenous
Heterogenous

51.  Low echoic area within the
lymph node with absence
of blood flow on Doppler
 Commonly seen in
Tuberculosis
Necrosis
No necrosis

52. Dhooria S, et al. JThor Cardiovasc Surg. 2014

54. If any of these is positive:Tuberculosis was more
likely
1. Xpert MTB/RIF
2. Tuberculin test
3. Coagulation necrosis sign
4. Heterogenous echotexture of lymphnode on
EBUS

55. If positive in any specimen: Sputum, BAL
Aspirated pus
 AFB smear
 Culture
 GeneXpert MTB/RIF
 Pus aspirated from lymph node, or any other
site

56. Sarcoidosis
 More than 2 times ULN

57.  Raised urinary calcium > 250 mg/24 hr
 Hypercalcemia
 Rarely seen inTuberculosis

58. SARCOIDOSIS TUBERCULOSIS: AFB +
NECROSIS +
 Caseating necrosis
 Ill formed granuloma
 Intense inflammatory reaction
 AFB +
•Noncaseating
•Compact granulomas
•Sparse lymphocytic cuffing around
granuloma (‘naked’)
•With inclusion bodies at times

59.  Sarcoidosis may fail to improve with ATT,
however in some spontaneous resolution
may occur
 Tuberculosis may worsen with steroids

60. Sarcoidosis Tuberculosis
Presentation Walk-in Brought-in
Behaves like Autoimmune disease Infectious disease
Granuloma Non caseating (No central
necrosis
Caseating (Central
necrosis)
Hemoptysis, expectoration Uncommon Common
Lacrimal, parotid and myocardial
involvement
Common Uncommon
Pleural, peritoneal, meningeal and
adrenal involvement
Uncommon Common
Tuberculin test Nearly always negative Nearly always positive
ACE levels > 2 ULN Common Less common
Increased S. Ca and 24 urinary Ca >
250 mg/24 hr
Common Not seen

61. SARCOIDOSIS: SYMMETRICAL
WITHOUT CENTRAL NECROSIS
TUBERCULOSIS:ASYMMETRICAL
WITH CENTRAL NECROSIS

62. SARCOIDOSIS: PERILYMPHATIC
NODULES
TUBERCULOSIS:
CENTRILOBULAR NODULES

63. SARCOIDOSIS: COBBLESTONE TUBERCULOSIS: ULCERATIVE

64. SARCOIDOSIS
 TBNA/EBUS
 EBB if endobronchial
granularity is present
 TBLB if parenchymal
involvement in HRCT
 Biopsy of involved area ?
Labial biopsy
TUBERCULOSIS
 TBNA/EBUS
 Aspirate pus
 BAL
 AFB smear and culture
 GeneXpert MTB/RIF

65. SARCOIDOSIS
 No AFB
 No necrosis
TUBERCULOSIS: AFB +
NECROSIS +

66. Sarcoidosis Tuberculosis
ATT No response Good response unless
MDR
Steroids Dramatic
clinicoradiologic
response
No response

67.  Thank you !