Pulmonary Tuberculosis and Sarcoidosis Presented With Pleuropericardial Effusion: A Challenging Case Report

Abstract

Differentiating tuberculosis (TB) from sarcoidosis, especially in TB endemic regions, is one of the major clinical challenges because these two diseases may show considerable similarity in terms of clinical manifestations, imaging findings, and granulomatous pattern. In addition, the presence of noncaseating granuloma alone is not sufficient for the definitive diagnosis of sarcoidosis because in some cases, TB may also show granulomas without necrosis. In this report, a 83-year-old man is presented with fever, productive cough, chest pain, weakness, and mild dyspnea, who had a history of pleural and pericardial effusion, with elevated pericardial adenosine deaminase (ADA), a positive tuberculin skin test, and pleural granuloma. The patient was initially treated with anti-TB therapy for probable diagnosis of TB pleurisy and also corticosteroid for probable sarcoidosis, but because of the development of drug-induced hepatitis, treatment was interrupted and modified several times. On subsequent presentation, chest high-resolution computed tomography (HRCT) showed pericardial thickening, pericardial effusion, pulmonary nodules with a perilymphatic distribution, right hilar lymphadenopathy, and a cavitary lesion in the right upper lobe. Sputum smear was 3+ positive for acid-fast bacilli, and anti-TB treatment was reinitiated. Nevertheless, because of the imaging pattern, relative response to corticosteroid, and pathologic findings including non-necrotizing granulomas, the possibility of concurrent sarcoidosis was also raised. After evaluating the possibility of TB progression and the effect of interruptions in anti-TB therapy caused by drug-induced hepatitis, the patient was treated with anti-TB regimen together with prednisolone and later azathioprine. Hence, the clinical case of pulmonary TB and probable sarcoidosis has been described in this study. The patient underwent anti-TB and immunosuppression therapy and experienced significant improvement.