PO38 - Tuberculosis, malignancy or Sarcoidosis? A diagnostic puzzle in an HIV Patient
Carlos Mendes Araújo (Portugal)1; Jorge Soares (Portugal)1; Miguel Lopes (Portugal)1;
1 - Local Health Unit Almada-Seixal, Almada, Portugal;
Keywords: Sarcoidosis; HIV; Differential diagnosis;
Select the theme: Challenges in Sarcoidosis Diagnosis and Staging
Type: Clinical Cases
Presentation: Poster Presentation

Introduction: Sarcoidosis in HIV-infected patients is rare due to CD4+ T-lymphocyte depletion impairing granuloma formation. With antiretroviral therapy (ART), immune reconstitution may unmask Sarcoidosis, presenting diagnostic challenges in distinguishing it from opportunistic infections, particularly Tuberculosis.

Clinical Case Description: A 53-year-old male from Mozambique was diagnosed with HIV-1 in December 2020, presenting with Nephrotic Syndrome (HIV-associated nephropathy, now on hemodialysis awaiting renal transplant). He initiated ART with excellent virologic response. Initial workup revealed indeterminate IGRA, positive interferon-gamma ELISPOT, and pancytopenia, raising concern for Miliary Tuberculosis.

Extensive investigation to exclude Tuberculosis included (February 2021): bone marrow biopsy showing reactive hyperplasia without granulomas, with negative PCR/ culture for M. tuberculosis and Non-tuberculous mycobacteria; Chest CT demonstrated peri-hilar consolidation in the left upper lobe with adenopathy. Bronchoscopy revealed an endobronchial mass nearly obstructing the anterior segmental bronchus. Bronchoalveolar lavage and bronchial secretions showed negative PCR/culture for mycobacteria, negative fungal studies, and negative cytology for malignancy. Bronchial biopsies showed lymphoplasmocytic infiltrate with granulation tissue, inconclusive for malignancy.

Repeat bronchoscopy (April 2021) demonstrated lesion reduction, with biopsies revealing non-necrotizing granulomatous inflammation; histology negative for neoplasia; microbiological studies remained negative. Given non-diagnostic initial biopsies, CT-guided transthoracic biopsy confirmed non-necrotizing epithelioid granulomatous inflammation consistent with Sarcoidosis, without microbiological isolation.

Concurrent frontal macular lesions showed granulomatous inflammatory dermatosis consistent with cutaneous Sarcoidosis; 

After exhaustive exclusion of infectious and neoplastic etiologies across multiple tissue samples, multisystem Sarcoidosis was diagnosed (pulmonary with endobronchial involvement and probably cutaneous). Follow-up bronchoscopy and CT (2022) demonstrated complete resolution of the endobronchial lesion. Patient remains stable without active disease.


Conclusions: This case illustrates sarcoidosis in an HIV patient of African origin—a population with both high Tuberculosis burden, requiring exhaustive infection exclusion, and 2- to 3-fold higher Sarcoidosis incidence. Pulmonary involvement mimicked infection and malignancy. Clinicians should suspect Sarcoidosis in HIV patients with granulomatous disease when microbiological and histological workup is negative.