A 46-year-old man from Nepal presented for a tuberculosis contact study after his brother was diagnosed with tuberculosis. Chest imaging revealed nodular pulmonary involvement. Further testing found non-caseating granulomas and elevated ACE levels, leading to a diagnosis of sarcoidosis with multi-organ involvement rather than tuberculosis. The case demonstrates the value of chest imaging in primary care for diagnosing unexpected conditions.

1. Tuberculosis contact study:
An unexpected finding
Jiménez Muñoz, Beatriz; Rovira Marcelino, Gemma; de la Figuera von
Wichmann, Mariano.
Sardenya Primary Care Center, Barcelona, Spain.

2. Case description
46 years old male, from Nepal, living in Spain last
10 years.
Cholecystectomy in 1998
No chronic drugs
Married, two healthy children
No drugs allergies
No toxic habits
Testicular tuberculosis
diagnosed and treated
in Nepal in 1995.
Working as a cook. Now he
has his own family restaurant.

3. Case description
• He came to our primary care center, referred from the
hospital, for a Tuberculosis contact study: his brother
was diagnosed of smear-positive Tuberculosis, they
work together daily.
• He has no respiratory symptoms, fever, sweating or
other. No recent trips abroad.
• Not vaccinated against Tuberculosis.
• Physical examination:
Only minimal bibasal rales on lung auscultation.

4. Aditional test
 PPD is applied, pending result.
 We demand chest Rx.
The patient came back in 72 hours:
 PPD: Negative.
 We check the image test.

6. Aditional test
• CRP 7,4 mg/L, DHL 380 UI/L.
• Blood TB Quantiferon: Negative.
• Urinary antigens for Legionella and Pneumococo: Negative.
• Antigens for: influenza A/B, parainfluenza, SRV, CMV, adenovirus: Negative.
• HIV, HCV, HBV: Negative.
• Tumor markers: Negative.
 Pulmonar CT:
Nodular pulmonary involvement, predominantly in upper lobes. Mediastinal and hiliar bilateral involvement.

8. [ W ith the se find ing s, w e dec ide d to re fer the pa tie nt t o re spi rat ory ]
service for further testing
 Bronchoscopy: No endobronchial gross lesions.
 BAL: No Gram. KB y TB-CRP: Negative. Sputum culture: Negative.
5% hemosiderophages, 45% macrophages, 5% eosinophils, 15% PMN
leukocytes, 30% lymphocytes (lymphocytes T 87,00%: CD4 74,00%, CD8
13,00%).
Transbronchial biopsy: Non-caseating granulomas.

9. Aditional test
With all these results, the main diagnosis is granulomatous disease.
 Blood test: ACE: Elevated. ANCA, C3-C4, cryoglobulines, RF:
Negative.
 PET-CT: Supra and infra-diaphragmatic nodal involvement.
Pulmonary, splenic, hepatic, renal and bone nodular involvement.
Dilated ventricular chambers.
 Echocardiogram: Dilated left ventricle with apical aneurysm
without thrombus. LVEF 39%. Diastolic dysfunction. Moderate
MI.

11. Finally...
 The patient was diagnosed with
Sarcoidosis, with lung, liver, spleen, kidney,
heart, bone and adenopathic involvement.
 We started treatment with high-dose
prednisone and we referred the patient to
rheumatology and cardiology for further
controls.

12. Conclusions
 We shouldn´t forget the importance of chest
radiography as a quick, cheap and accessible method
for the diagnosis of many diseases, even if the findings
do not point to our primary suspected diagnosis.
 As primary care physicians, we are a vital link in
screening for multiple diseases. Our fast-acting, with
progressive and consistent application of additional
tests can make a clear difference in the prognosis of
our patients.

13. Thank you!, ¡Gracias!