An exhaustive and comprehensive presentation of Curofy Expert Clinical case by Dr Viral Patel - a really informative case Patient was lucky to have his ACE levels raised to 143 - although few patients have even normal ACE levels. It is one of the rare cases of disseminated tuberculosis Co- existing with sarcoidosis Distinguishing sarcoidosis from pulmonary tuberculosis can sometimes be a great challenge to physicians, especially in developing countries where there is high prevalence of tuberculosis. Both tuberculosis and sarcoidosis are granulomatous diseases, however, tuberculosis has a caseating granuloma as opposed to sarcoidosis, which present with non-caseating epithelioid cell granuloma. Due to the marked clinico-radiological similarity of these entities and high prevalence of tuberculosis, these patients receive repeated courses of anti-tubercular therapy (ATT) while lung damage continues to progress. Thanks Dr Viral Patel for this case and a young male was prevented from lung damage
Absolutely sarcoidosis is under diagnosed and still rarely thought along with tuberculosis In given case it was still more difficult when the pt is covid positive as most comoonly seen is pulmonary fibrosis but you thought otherwise and marker like SACE considered and found positive But limitations of treatment are to depend on steroids Thanx for sharing a well informed case
Steroids are not for purpose of tuberculosis here, it's for coexisting Sarcoidosis. Steroids in tuberculosis are useful in following conditions :- 1)Tubercular Pleural effusion 2)Tubercular Meningitis 3)Tubercular pericarditis 4)Associated Adrenal insufficiency 5)IRIS/Paradoxical response 6)Co-existence of Sarcoidosis or other autoimmune disease
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NICE ILLUSTRATION OCCULAR COMMENTS IF SARCOIDOSIS ARE ANT SEGMENTAL MANEFESTATIONS POST SEGMENT MANEFESTATIONS ANT SEGMENT ARE SARCIOD PLAQUES LIKE CHLAZIA LACRIMAL GLAND INVOLVEMENT FOLLICULAR CONJUCTIVITS PHELETENULAR CONJUCTIVITS HETROCHROMIA IRIS NODULE SCLERITIS BIL GRANULOMATOUS PANUVEITIS ACUTE UVEITIS 40 PERCENT 60 PERCENT CHRONIC UVEITIS POST SEGMENT MANEFESTATIONS PRE RETINAL MODULE CHORIODAL INVOLVEMENT CANDLE WAX APPEARANCE PERIVASCULITIS VENOUS OCLUSION GRANULOMA.OF DISC GRANULOMA OF RETINA
It's a case to enlighten us regarding under noticed Sarcoidosis in TB endemic zones like India. Co-existence is also under noticed in similar way. We need to keep high index suspicion for this sort of scenario. We need to guide our management as per Histopathological opinion along with radiological guidance. Markers like ACE level are very helpful in such issues.
CAUSES OF BILATERAL GANULOMATOUS PANUVEITIS THEY ARE 1 S OPHTHALMIC 2 V K H DESEASE 3 BECHETES DESEASE 4 SARCIODISIS 5 H I V 6 TUBERCULOSIS 7 SYPHLIS 8 INFECTIVE ENDOPHTHALMITIS 9 ABSTEIN BAR VIRUS
Excellent , to the point explanation showing salient features of tuberculosis & sarcoidosis & tuberculous sarcoidosis.
Nice case presentation.indeed sarcoidosis is never considered in association with tuberculosis.really very helpful.
Really a very informative case presentation by Dr Viral patel . But as in starting slides it is mentioned that Patient was also recieving steroids with other treatment. But was not improvement but he diagnosed histopathologically sarcoidosis then improvement seen on prednisolone so i want to know that is it only prednisolone as steroid got result in sarcoidosis or we can use any steroid as so many forms available if yes then why Patient was not improving during Admission earliar when he was recieved steroid too with other treatment. Please exlain Dr patel please? Thanks
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SARCOIDOSIS. Sarcoidosis is a multi system inflammatory disorder of unknown etiology that predominantly affects the lungs and intra thoracic lymph nodes. Sarcoidosis is manifested by the presence of non caseating granulomas ( NCG's ) in affected organs. It is characterised by a seemingly exaggerated immune response against a difficult - to - discern antigen. SIGNS AND SYMPTOMS. The presentation of sarcoidosis depends on the extent and severity of organ involvement. *Asymptomatic. *Systematic complaints like fever and anorexia. *PULMONARY MANIFESTATION Dyspnea on exertion. Cough. Chest pain Hemoptysis. Pulmonary findings on physical examination can be Usually normal. Crepitus. External oxygen desaturation. LOFGREN SYNDROME. Fever,bilateral hilarious lymphadenopathy and polyarthralgias. DERMATOLOGICAL MANIFESTATION. *-Erythema nodosum. *A lower extremity panniculitis with painful erythematous nodules. *Lupus permit ( the most specific associated cutaneous lesion ) *Violaceous rash on cheeks and nose ( common ) *Maculopapular plaques ( uncommon ) OCULAR MANIFESTATION. *Anterior or posterior granulomatous uveitis. *Conjunctival lesions and scleral plaques. If untreated can lead to blindness. OTHER POSSIBLE MANIFESTATION. *Osseous involvement. *Heart failure from cardiomyopathy. *Heart block and sudden death. *Lymphocytic meningitis. *Cranial nerve palsies and hypothalamic / pituitary dysfunction. DIAGNOSIS. *Chest X-RAY central to the evaluation. *High resolution CT identifies active alveolitis versus fibrosis. *Gallium scans. *Pulmonary function tests and carbon monoxide diffusion capacity test of the lungs( DLCO ) for carbon monoxide is used routinely in evaluation and follow up. An isolated decrease in DLCO is the most common abnormality. *Cardiopulmonary exercise testing is a sensitive test for identifying and quantifying the extent of pulmonary involvement.I t also suggests cardiac involvement that otherwise is not evident. IMPAIRED HEART RATE RECOVERY DURING THE FIRST MINUTE FOLLOWING EXERCISE HAS BEEN SHOWN TO BE AN INDEPENDENT PREDICTOR FOR CARDIOVASCULAR AND ALL CAUSE MORTALITY. DIAGNOSIS REQUIRES BIOPSY IN MOST CASES.ENDOBRONCHIAL BIOPSY VIA BRONCHOSCOPY IS OFTEN DONE.THE CENTRAL HISTOLOGICAL FINDING IS THE PRESENCE OF NON CASEATING GRANULOMAS WITH SPECIAL STAINS NEGATIVE FOR FUNGUS AND MYCOBACTERIA. *Hypercalcemia. *Hypercalcuria. *Elevated alkaline phosphatase level. *Elevated angiotensin converting enzyme level. STAGING OF SARCOIDOSIS. STAGE O : Normal chest radiographic findings. STAGE I. : Bilateral hilar lymphadenopathy. STAGE II : Bilateral hilar lymphadenopathy and infiltrates. STAGE III : Infiltrates alone. STAGE IV : fibrosis. TREATMENT. Most patients do not require therapy and their condition improves spontaneously. Markers for poor prognosis are Advanced chest radiography stage. Extra pulmonary disease Evidence of pulmonary hypertension. Most patients require symptomatic treatment with NSAID 's for treatment of arthralgias. Treatment for patients with pulmonary involvement. *Asymptomatic patients do not require treatment. *In patients with minimal symptoms,serial re evaluation is prudent *Treatment is indicated for patients with severe symptoms. *Corticosteroid are helpful. *For extra pulmonary sarcoidosis involving heart,liver,eyes,kidney and central nervous system , corticosteroid therapy is indicated. *Topical steroids are useful for ocular disease. Common indications for non - corticosteroid are *Steroid resistant disease. *Intolerable adverse effects of steroids. Non corticosteroid agents are METHOTREXATE CHLOROQUINE and HYDROCHLOROQUINE used for cutaneous lesion,hypercalcemia,neurologic sarcoidosis and bone lesions. CHLOROQUINE is useful for Acute and maintenance treatment of chronic pulmonary sarcoidosis. CYCLOPHOSPHAMIDE is used in refractory sarcoidosis. AZATHIOPRINE is best used as a steroid sparing agent. CHLORAMBUCIL is beneficial in patients with progressive disease unresponsive to steroids. CYCLOSPORINE is of limited benefit in skin sarcoidosis or in progressive sarcoidosis resistant to conventional therapy. INFLIXIMAB & THALIDOMIDE are used for refractory sarcoidosis. FOR PATIENTS WITH ADVANCED PULMONARY FIBROSIS FROM SARCOIDOSIS,LUNG TRANSPLANTATION REMAINS THE ONLY HOPE FOR LONG TERM SURVIVAL. LONG TERM MONITORING. *Monitor pulmonary function and chest radiography every 6 months. *Assess for progression or resolution. *Determine if previously uninvolved organs have become affected. *Annual slit lamp examination and ECG are recommended.Dr. Suvarchala Pratap19 Likes20 Answers
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