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EDITORIAL
Year : 2009  |  Volume : 26  |  Issue : 1  |  Page : 1-2 Table of Contents   

Tuberculosis and sarcoidosis: The continuing enigma


Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012, India

Correspondence Address:
Dheeraj Gupta
Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-2113.45194

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How to cite this article:
Gupta D. Tuberculosis and sarcoidosis: The continuing enigma. Lung India 2009;26:1-2

How to cite this URL:
Gupta D. Tuberculosis and sarcoidosis: The continuing enigma. Lung India [serial online] 2009 [cited 2020 Jan 27];26:1-2. Available from: http://www.lungindia.com/text.asp?2009/26/1/1/45194

Though the famous Norwegian dermatologist Caesar Boeck who probably for the first time described sarcoidosis as "multiple benign sarcoid of the skin" in 1899, thinking that the histological features resembled sarcoma, its remarkable similarity to tuberculosis in both clinical and histological features was soon noticed and a possible link between the two conditions has been debated ever since. [1] The possible relationship can have implications in three areas: a) pathogenesis, b) diagnosis, and c) treatment.

The granulomatous inflammation in sarcoidosis is believed to be in response to the continued presentation of a poorly degradable, and yet to be identified antigen. [2] Numerous etiologic agents have been incriminated, both infective and noninfective. [3] Among the infective agents, the two strong contenders are the propionibacterium and the mycobacterium. [4] However recently, Propionibacterium acnes was shown to be a common commensal on culture and polymerase chain reaction (PCR) analysis from lung tissues and lymph nodes of subjects with and without sarcoidosis. [5] Also, the inability to isolate mycobacteria by histological staining or culture from tissues in sarcoidosis continues to be one of the strongest arguments against a potential role of mycobacteria. Of late, molecular analysis (such as PCR techniques) for nucleic acids of the Mycobaterium tuberculosis (MTB) or non-tubercular mycobateria (NTM) have added more insight into the issue. A recent meta-analysis by us of all such studies conducted from 1981-2006 revealed 31 studies that had used PCR for nucleic acid amplification followed by identification of nucleic acid sequences specific for different types of mycobacteria. [6] Overall, 231 out of the 874 patients were positive for mycobacteria with a positive signal rate of 26.4% (95% CI, 23.6-29.5), and the odds of finding mycobacteria in samples of patients with sarcoidosis versus controls were 9.67 (95% CI, 4.56-20.5). [6] These results clearly show that the association does exist in a significant proportion of patients. [7] Moreover, all these studies have been from populations with low prevalence (exposure) of tuberculosis and the possible role of tuberculosis in causation of sarcoidosis in high prevalence countries including India remains to be explored.

Tuberculosis, as a differential diagnosis of sarcoidosis poses even a greater challenge to clinicians, particularly in countries like India with a high prevalence of tuberculosis. The tuberculin sensitivity is depressed in sarcoidosis even in the background of high prevalence of tuberculosis and a cut-off of 10 mm reaction to 5TU tuberculin test has virtually 100% sensitivity for sarcoidosis, however, it is not specific. [8] The problem is further confounded by the coexistence of two diseases. [9] The diagnosis of sarcoidosis rests on a constellation of clinical, radiological, histopathological, and laboratory data. [10]

Finally, if indeed tuberculosis is a causal factor in sarcoidosis, then the hypothesis can be further reinforced, if antitubercular therapy (ATT) is useful in treatment of sarcoidosis. Very few trials have been conducted in the past but the results of these trials have been discouraging. These trials were generally small studies and limited by time bias and used older regimens based on isoniazid, amino-salicylic acid, and streptomycin. [11],[12] In our experience, nearly one-third of patients who are finally diagnosed to have sarcoidosis, have received ATT for variable lengths of time, but its impact on the final outcome of sarcoidosis has not been studied. Role of antimicrobial therapy in sarcoidosis has recently been reviewed and it gives us a definite thought for the future. [13]

 
   References Top

1.Sharma OP. Murray Kornfeld, American College Of Chest Physician, and sarcoidosis: A historical footnote: 2004 Murray Kornfeld Memorial Founders Lecture. Chest 2005;128:1830-5.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Perez RL, Rivera-Marrero CA, Roman J. Pulmonary granulomatous inflammation: From sarcoidosis to tuberculosis. Semin Respir Infect 2003;18:23-32.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Newman LS. Aetiologies of sarcoidosis. Eur Respir Mon 2005;32:23-48.  Back to cited text no. 3    
4.Drake WP, Newman LS. Mycobacterial antigens may be important in sarcoidosis pathogenesis. Curr Opin Pulm Med 2006;12:359-63.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Ishige I, Eishi Y, Takemura T, Kobayashi I, Nakata K, Tanaka I, et al. Propionibacterium acnes is the most common bacterium commensal in peripheral lung tissue and mediastinal lymph nodes from subjects without sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 2005;22:33-42.  Back to cited text no. 5  [PUBMED]  
6.Gupta D, Agarwal R, Aggarwal AN, Jindal SK. Molecular evidence for the role of mycobacteria in sarcoidosis: A meta-analysis. Eur Respir J 2007;30:508-16.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Jindal SK. Mycobacterial relationship of sarcoidosis: The debate continues. Expert Rev Respir Med 2008;2:139-43.  Back to cited text no. 7    
8.Gupta D, Chetty M, Kumar N, Aggarwal AN, Jindal SK. Energy to tuberculin in sarcoidosis is not influenced by high prevalence of tuberculin sensitivity in the population. Sarcoidosis Vasc Diffuse Lung Dis 2003;20:40-5.  Back to cited text no. 8  [PUBMED]  
9.Smith-Rohrberg D, Sharma SK. Tuberculin skin test among pulmonary sarcoidosis patients with and without tuberculosis: Its utility for the screening of the two conditions in tuberculosis-endemic regions. Sarcoidosis Vasc Diffuse Lung Dis 2006;23:130-4.  Back to cited text no. 9  [PUBMED]  
10.Jindal SK, Gupta D, Aggarwal AN. Sarcoidosis in India: Practical issues and difficulties in diagnosis and management. Sarcoidosis Vasc Diffuse Lung Dis 2002;19:176-84.  Back to cited text no. 10  [PUBMED]  
11.Hoyle C, Dawson J, Mather G. Treatment of pulmonary sarcoidosis with streptomycin and cortisone. Lancet 1955;268:638-43.  Back to cited text no. 11  [PUBMED]  
12.James DG, Thomson AD. The course of sarcoidosis and its modification by treatment. Lancet 1959;1:1057-61.  Back to cited text no. 12  [PUBMED]  
13.Tercelj M, Salobir B, Rylander R. Microbial antigen treatment in sarcoidosis: A new paradigm? Med Hypotheses 2008;70:831-4.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]



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