Tubercular Neuro-Osseous-Pulmonary Sarcoidosis - A Challenging Combination

Neuro-Osseo-sarcoidosis is a rare presentation and tubercular etiology for sarcoidosis is always debatable. We had a middle-aged woman who presented with symptoms and signs suggestive of chronic meningitis including arachnoiditis and was further investigated for probable etiologies with CSF study being equivocal with high proteins and normal cell counts. She had contact family history of tuberculosis. On imaging studies, MRI and MRI lumbosacral spine revealed lesions consistent with neuro-osseo-sarcoidosis following which biopsy taken from bony lesions was inconclusive. CT-chest done to see pulmonary involvement suggested typical features of sarcoidosis. She was started with corticosteroids and she had improvement in her symptoms and regain of appetite suggesting response to treatment and confirms diagnosis of disseminated sarcoidosis. On follow-up after 1months, there was deterioration further in general condition with appearance of new onset focal seizures and neuroimaging suggested multiple ring lesions consistent with tuberculoma along with chest CT imaging showing cavitatory lesions in left lung. However, there were partial/complete regressions of all previous lesions in brain and chest. Bronchoalveolar lavage suggested positive acid-fast bacilli and CBNAAT confirmed rifampicin sensitive Mycobacterium tuberculosis. Hence coexistence of tuberculosis and sarcoidosis, reactivation of tuberculosis, or tuberculosis as probable etiology for sarcoidosis could not be ruled out.