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Respiratory Division Academic Hospital AZ-VUB Brussels, Belgium
To the Editor:
Patients presenting features of both sarcoidosis and tuberculosis (whether or not in causative relationship) can be quite puzzling to the pulmonary physician, as was pointed out in a recent issue of CHEST by Wong and colleagues (August 1998)1 and, in a splendid accompanying editorial, by Dr. Baughman.2
The authors and the readers of CHEST may be interested in a paper published in the European Journal of Internal Medicine,3 in which we described the case histories of three patients with "overlap features" of both disorders, and in whom extensive diagnostic workup (though not including polymerase chain reaction search for mycobacterial DNA) and response to therapy did not allow unequivocal classification into diagnosis of either sarcoidosis or tuberculosis. In this paper, we also refer to several other reports in the literature on "concomitant" sarcoidosis and tuberculosis that were not quoted by Wong and colleagues, but which may be of interest in this debate.
Finally, although I fully acknowledge the diagnosis of sarcoidosis at the second admission of Wong's patient, would not the authors expect a search for mycobacterial DNA in pulmonary tissue, 13 months after a documented tuberculous infection, to be positive in every case?
Correspondence to: Marc M. P. Noppen, MD, FCCP, Respiratory Division, Academic Hospital AZ-VUB, 101 Laarbeeklaan, Brussels 1090, Belgium; email: pnennm@az.vub.ac.be
References
Grantham Hospital Aberdeen, Hong Kong
To the Editor:
I thank Dr. Noppen for his interest in our case report.1 I am sure the three cases described in his paper published in the European Journal of Internal Medicine2 would be of great interest. However, I did not have the chance to read this article because it is not available on MEDLINE.
I agree that diagnosis of sarcoidosis can be very difficult, especially in areas where tuberculosis has a high prevalence. Usually, one can confidently diagnose sarcoidosis only after extensive mycobacteriologic studies have failed to reveal the presence of Mycobacterium tuberculosis. Alternatively, sarcoidosis can be diagnosed in a patient who has received a course of antituberculous treatment with no improvement, as in our reported case.
Concerning the detection of mycobacterial DNA by polymerase chain reaction (PCR) in patients with treated or inactive tuberculosis, it has been well reported that PCR can be positive in the respiratory specimens from patients with treated or inactive tuberculosis.3 4 A study conducted in our unit and recently published5 may also give some data on this issue. In the study, among 82 patients not suffering from active pulmonary tuberculosis, bronchial aspirate for PCR was positive in 22 cases. Among these 22 PCR-positive cases, 12 had evidence of previous tuberculosis whereas in the PCR-negative counterparts, 22 of 60 had evidence of previous tuberculosis. This showed that PCR can be positive in some, but not all, cases of treated tuberculosis.
In our reported case, the patient had well-documented tuberculous lymphadenitis but not pulmonary tuberculosis. As stated in the case report, we believed that the patient had sarcoidosis involvement of the lungs and other organs.
Correspondence to: Chi Fong Wong, MBBS, FCCP, Tuberculosis and Chest Unit, Grantham Hospital, 125 Wong Chuk Hang Road, Aberdeen, Hong Kong
References
This article has been cited by other articles:
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  I Litinsky, O Elkayam, G Flusser, R Segal, M Yaron, and D Caspi Sarcoidosis: TB or not TB? Ann Rheum Dis, May 1, 2002; 61(5): 385 - 386. [Full Text] [PDF]
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