Sarkoidoza ili milijarna tuberkuloza – prikaz bolesnika

Prikazan je bolesnik u dobi od 59 godina s dugotrajnim febrilitetom i kašljem koji je razvio oštećenje jetre. Biopsijom jetre je dokazana nekazeozna granulomatozna upala. Vrijednost angiotenzin konvertirajućeg enzima je bila povišena (85 U/L). Opetovano uzimane hemokultura, kultura urina i kultura likvora su bile sterilne. U iskašljaju nije detektiran mikobakterij. Obzirom na navedeno, postavljena je sumnja na sarkoidozu te je započeta terapija kortikosteroidom. Usprkos terapiji, stanje bolesnika se pogoršavalo. Razvilo se akutno zatajenje bubrega do potrebe za hemodijalizom te parcijalna respiratorna insuficijencija. MSCT toraksa je pokazao sitnonodularni intersticijski infiltrat, pretežno u gornjim režnjevima pluća, uz povećane medijastinalne limfne čvorove, te konglomerat uvećanih mjestimično kolikviranih limfnih čvorova subkarinarno. Direktni preparat bronhoalveolarnog lavata u dva navrata i transbronhalna aspiracija iglom bili su negativni na bacil tuberkuloze. Nakon pregleda očne pozadine postavljena je sumnja na diseminiranu tuberkulozu. Mycobacterium tuberculosis, osjetljiv na streptomicin, izonijazid, etambutol, rifampicin, pirazinamid, naknadno je porastao u kulturi koštane srži. Uz antituberkulotsku terapiju bolesnik je trajno bio febrilan 21 dan. Nakon pet mjeseci terapije bolesnik se potpuno oporavio, uključujući i potpuni oporavak bubrežne funkcije.
We present a previously healthly 59-year-old patient with fever, cough and liver disease. Liver biopsy showed non-necrotizing ("non-caseating") granulomas. The level of angiotensin-converting enzyme was above the reference range (85 U/L). Blood, urine and cerebrospinal fluid cultures were repeatedly sterile. No mycobacteria were detected in the sputum. Given the above findings, sarcoidosis was suspected and corticosteroid therapy was initiated. However, the patient was getting worse and developed acute kidney injury together with partial respiratory insufficiency. The chest CT showed interstitial infiltrate, mainly in the upper lobes of the lung, mediastinal lymph node enlargement with partial colliquation. Bronchoscopic aspiration and bronchoalveolar lavage was performed two times; no Mycobacterium was detected. Transbronchial needle aspiration also found no Mycobacterium. Ophthalmologic examination revealed choroiditis and antituberculosis therapy was initiated. Mycobacterium tuberculosis was later detected in culture of bone marrow. After five months of antituberculosis therapy the patient completely recovered, his liver tests were normal as well as renal function.