Levaquin

INTRODUCTION: A miliary pattern of pulmonary sarcoid is rare and in fact, is difficult to distinguish from miliary tuberculosis. Similarly, bone involvement in sarcoid is infrequent and can be overlooked. We present a patient with known tuberculosis and disseminated sarcoid including involvement of the spleen, liver, and bone, and presenting in the lung as miliary disease.

CASE PRESENTATION: This is a case of a 53-year-old female with an established diagnosis of tuberculosis on treatment. The patient is a citizen of panama (who appears African-Carribean) and came to the U.S. in May 2004. She had no other medical history and had a recent normal pap smear and mammogram. She is a never smoker, uses rare alcohol and never used IV drugs. She works in a clothing factory as a clerk, has no known occupational exposures, and is HIV negative. In April she was diagnosed with sputum culture positive pansensitive tuberculosis and was started on INH, rifampin, pyrazinamide, and ethambutol. Chest radiograph revealed a left basilar infiltrate and miliary disease. In May, the patient developed hepatic failure thought secondary to the tuberculosis medications and was admitted to an outside hospital. The patient was discharged on streptomycin, levaquin, and ethambutol; sputums were AFB culture negative. Six weeks after the initiation of this regimen, the patient complained of dizziness. The patient was admitted to the Bellevue Hospital Chest Service in October for evaluation of her dizziness which had then been of 4 1/2 months duration. Tuberculosis medications were held. Neurologic exam was non-focal. Chest radiograph showed multiple small nodules unchanged from June, and resolution of the left infiltrate. A chest CT showed diffuse perilymphatic small (<1cm), well-defined, non-calcified, mainly non-cavitating nodules bilaterally, left basilar scarring and was interpreted as likely metastatic cancer. No effusions or adenopathy was noted. An abdominal CT scan noted a lesion in the liver, and diffuse granulomatous-type infiltration of the liver and spleen. Osseus lucencies suggestive of bone metastases were noted. A bone scan revealed uptake in the right femoral neck, T8 vertebra, and the calvarium. A brain MRI revealed multiple metastatic appearing lesions in the calvarium. A malignancy work-up ensued. The liver was biopsied with a cytopathology needle revealing non-necrotizing granulomatous inflammation and no malignancy. AFB was negative. A bronchoscopy was similarly unrevealing and AFB was negative. In January, rifabutin and isoniazid were restarted. The patient refused open-lung biopsy. A calvarial biopsy was performed revealing multiple non-caseating granulomas and no malignant cells. Cultures, including AFB, were negative. An ACE level was elevated at 160.

DISCUSSIONS: We diagnosed the patient with sarcoidosis, steroids have been started. There is some resolution of the patient's pulmonary nodules. The dizziness, which may be a cranial nerve dysfunction related to sarcoid, has diminished slightly. Follow-up imaging of the bone, liver and spleen involvment is planned.

CONCLUSION: We present an unusual case of concurrent tuberculosis and sarcoidosis, including a miliary pulmonary pattern without adenopathy, bone, diffuse liver and spleen involvement and possibly cranial nerve VIII dysfunction. This patient was initially misdiagnosed with miliary TB and later worked up for cancer. Miliary TB typically presents with multiple, small (1-5 mm) nodules that are randomly positioned in the parenchyma, and along the pleura and fissures. Miliary tuberculosis represents 1-3% of all tuberculosis cases. A miliary presentation of sarcoidosis is rare and can be very difficult to distinguish from tuberculosis and malignancy. The overall frequency of bone involvement in sarcoid is about 3% and is generally asymptomatic. The short bones of the hands and feet are usually involved while the long bones, and vertebrae are rarely involved.

REFERENCE:

(1) Fraser, Richard S, et al; Diagnosis of Diseases of the Chest, Fourth Edition. Vol 3. 1551-1563.

DISCLOSURE: Marilyn Kline, None.

Marilyn Y. Kline MD * Eric M. Leibert MD NYU Medical Center, New York, NY

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group