This document provides an overview of the similarities and differences between sarcoidosis and pulmonary tuberculosis, two granulomatous lung diseases that can be difficult to distinguish. Both commonly present with nonspecific constitutional symptoms but sarcoidosis typically causes a dry cough and fatigue, while tuberculosis often presents with a cough producing sputum and evening fevers. Diagnosis of sarcoidosis relies on biopsy evidence of non-caseating granulomas and usually excludes tuberculosis, whereas tuberculosis diagnosis requires identification of Mycobacterium tuberculosis via smear, culture or molecular testing. Distinguishing the two is important for determining appropriate treatment with corticosteroids or anti-tubercular drugs, respectively.

1. SARCOIDOSIS
V/S
PULMONARY TUBERCULOSIS
“A DIANOSTIC DILEMMA”
By Dr. Gouri Mohan | JR1-Respiratory Medicine

2. DEFINITION
SARCOIDOSIS
 Inflammatory disease
characterized by the presence of
non-caseating granulomas.
 Lung (m/c) : >90%
TUBERCULOSIS
 Severe and contagious
disease caused by M.
tuberculosis complex
 Lung (m/c) : 79.4%
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 Presentation of Sarcoidosis ranges from patients who are asymptomatic to those
with organ failure.
 Constitutional symptoms like fever, malaise, fatigue, weight loss and night
sweats are non-specific and common to both the diseases.
However, fatigue is an important symptom of Sarcoidosis.
While evening rise of temperature and night sweats are marked in TB.

4. RESPIRATORY SYMPTOMS
SARCOIDOSIS
 Dry cough, breathlessness usually
of insidious and progressive in
nature.
 Shortness of breath typically
worsens with exertion.
PULMONARY TB
 Usually presents with cough with
expectoration(initially cough may
be dry)
 Classically TB presents insidiously
over weeks with persistent h/o
above mentioned symptoms.
Hemoptysis although not exclusive
to TB is more frequently encountered
than in Sarcoidosis 4

5. OTHER ORGANS COMMONLY
AFFECTED IN SARCOIDOSIS
 Skin (20-30%)
 Ocular (20-30%)
 Hematologic (20-30%)
 Hepatic/Abdominal(10-20%)
 Joints & musculoskeletal(10-20%)
 Exocrine (10-20%)
 Endocrine (10-20%)
 Cardiac (5-20%)
 Neurologic (5-10%)
 URT & Oral cavity (5-10%)
 Renal (<10%)
 GUT (<5%)
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SKIN MANIFESTATION
LUPUS PERNIO

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OCULAR INVOLVEMENT
 Anterior uveitis (m/c)
 Lacrimal gland involvement
 Scleral nodules
 Chorioretinitis
 Conjunctivitis
 Optic neuritis

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 LIVER INVOLVEMENT : Elevation of ALP, Transaminase, Bilirubin(marker of
more advanced liver disease)
Portal hypertension – Ascites and Esophageal varices.
 CARDIAC INVOLVEMENT : Cardiomyopathy (Dilated >Restrictive),
BBB/Arrhythmias
 NERVOUS SYSTEM INVOLVEMENT : Aseptic meningitis/encephalitis, Cranial
neuropathy, Peripheral neuropathy, Central DI, Optic neuritis.
 HEMATOLOGICAL : Mediastinal LN Involvement, Hypersplenism leading to
Anemia, Thrombocytopenia

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There are certain conditions where the clinicoradiological
manifestations are typical for Sarcoidosis – LOFGREN
SYNDROME, HEERFORDT SYNDROME.

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TUBERCULOSIS
TB is predominantly a respiratory disease affecting Lungs in approx. 80% of cases.
 About 30% of TB cases involve an extrapulmonary site, occurring with or without
concomitant Lung involvement.

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ORGANS AFFECTED IN EXTRAPULMONARY
TB : 20.6%
Lymph node (7.6%)
Pleural (4%)
Bone and joint(1.8%)
Peritoneal (1.3%)
Meningeal (0.9%)
GUT (0.9%)
Others (5.3%)

13. EXTRAPULMONARY
TB
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Common Forms

14. PHYSICAL EXAMINATION
SARCOIDOSIS
 Physical findings are infrequent, with
lung crackles heard in <20% of
patients.
 Clubbing is rare.
PULMONARY
TUBERCULOSIS
 Even when relatively extensive
disease is present, Pul TB most
often produces no detectable
abnormality on physical
examination.
 Tachypnea and Hypoxia are
relatively rare, unless there is
extensive lung destruction or miliary
disease 14

15. DIAGONOSTIC APPROACH
SARCOIDOSIS
 Is almost always a diagnosis of
exclusion.
 There is no reliable, non-invasive
screening test to help confirm a
diagnosis.
 Diagnosis is based on compatible clinical
and radiological manifestations together
with a tissue biopsy.
PULMONARY
TUBERCULOSIS
 The key to early diagnosis is a high index of
suspicion, considering epidemiological risk
factors and suggestive clinic-radiological
features.
 Ultimately the definitive diagnosis requires a
culture confirmation
 In case of high clinical suspicion due to
radiological findings , Culture –ve d/s is the
diagnosis if radiological findings improves
with treatment
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16. LABORATORY FINDINGS
SARCOIDOSIS
 Lymphopenia(m/c), Anemia (20%),
Thrombocytopenia – Pancytopenia in
some patients.
 Hypercalcemia and / or
hypercalciuria occur in about 10% of
Sarcoidosis patients
 Elevated ACE Levels
 TST –ve
PULMONARY
TUBERCULOSIS
 AFB Microscopy
 Gene Xpert for MTB which also detects drug
resistance (Rif)
 Mycobacterial Culture remains the gold std.
 Anemia
 TST can be positive but with low specificity
and sensitivity
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17. CHEST X RAY
IN
SARCOIDOSIS
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18. CHEST X RAY
IN
SARCOIDOSIS
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19. CHEST X RAY
IN
TUBERCULOSIS
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Although “classic
picture” is that of
upper lobe
infiltration &
cavities, virtually
any radiographic
pattern from a
normal film or a
solitary pulmonary
nodule to diffuse
alveolar infiltrates
may be seen

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TISSUE BIOPSY

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SARCOIDOSIS : TREATMENT

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 PREDNISOLONE 20-40 mg/day - - - - taper to 5-10mg/day
Treatment is usually continued for 6-24 months
 Inhaled steroids appeared to have limited effectiveness in Chronic Pulmonary
Sarcoidosis and are not recommended as sole therapy
 ALTERNATIVE AGENTS : Methotrexate, Chloroquine, Azathioprine, Infliximab

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MANAGEMENT OF TUBERCULOSIS
 ANTI-TUBERCULAR THERAPY

33. Thank you