In January 2009, a 27-year-old Asian man initially presented to his general practitioner with a 4-month history of weight loss totalling 9 kg and general malaise. Clinical examination revealed cervical and axillary lymphadenopathy. He had no significant past medical history and was not on regular medications. His younger brother was known to have sarcoidosis. Initial blood tests including full blood count (Hb 14.9g/dl, WBC 4.3 109/L, Neutrophils 2.95 109/L, Lymphocytes 0.72 109/L, ESR 9 mm), urea and electrolytes, thyroid and liver function tests only revealed a mildly raised alkaline phosphatase. His HIV test and standard tuberculin test were negative. Interestingly, serum angiotensin converting enzyme level was elevated at 156 U/L (normal range 8-52 U/L), which can serve as an indicator for tuberculosis.
Chest X-ray revealed marked hilar and mediastinal lymphadenopathy. An urgent CT (computed tomography) scan of the thorax, abdomen, pelvis and referral to the respiratory physicians were advised. CT thorax findings raised the possibility of tuberculosis (TB), lymphoma or sarcoidosis. To confirm a diagnosis, the patient underwent a bronchoscopy in February 2009 by the respiratory physicians and the bronchial brush biopsy. A lymph node biopsy was carried out by the General Surgical Team and specimens were sent for tuberculosis culture and histology including haematological malignancies diagnostic services (HMDS).
The differential diagnosis of tuberculosis or lymphoma was considered. While awaiting cultures and pathology results on the above procedures the patient opted to have anti-tuberculosis treatment empirically. Interestingly, all sputum samples and bronchial washings were TB culture negative. His bronchial biopsy showed granulomatous inflammation and raised the possibility of tuberculosis or sarcoidosis. Unfortunately, the lymph node biopsy taken at presentation was not processed in error. In April 2009, he noticed a left sided painless testicular and epididymal swelling. A scrotal ultrasound scan showed a hyperechoic area within the left testis and he was referred to the urology unit. Additionally, despite negative culture findings, on balance, the patient was recommended to complete a six month course of anti-TB treatment.
In May 2009, he complained of diplopia. Fundoscopic examination revealed a mild posterior uveitis. This can be a feature of both tuberculosis and sarcoidosis.
The patient was reviewed in the urology clinic. He gave a 1 year history of progressive left sided testicular and epididymal swelling. This was painless, and he had no urinary symptoms. Examination revealed a firm, non-tender mass, which included the left epididymis and testis.
Ultrasound examination revealed a hyper echoic region within the left testis. Of note, betaHCG (human chorionic gonadotropin), AFP (alpha-fetoprotein) and LDH (Lactate dehydrogenase) were within normal range. As malignancy could not still be ruled out, the patient underwent a left inguinal orchidectomy and inguinal lymph node biopsy. A frozen section not considered due to clinical and radiological findings. Histology from the above procedure confirmed a diagnosis of sarcoidosis (Figure 1).
The patient was commenced on steroid treatment which was continued this for 2 years and is undergoing annual follow-up appointments with the respiratory physicians.