A Unique Case of Abdominal Sarcoidosis Presenting as Conglomerated Lymphadenopathy in a Tuberculosis Endemic Region: A Diagnostic Dilemma Resolved by Endoscopic Ultrasound-guided Biopsy

Abstract

Sarcoidosis is a multisystem granulomatous disorder characterized by noncaseating granulomas and most commonly involves the lungs and intrathoracic lymph nodes. Although pulmonary involvement predominates, extrapulmonary manifestations such as abdominal lymphadenopathy may occur and can closely mimic infectious etiologies in tuberculosis-endemic regions like India. We report a 64-year-old female with diabetes mellitus, hypertension, and coronary artery disease who presented with cough, exertional dyspnea, intermittent fever, and significant weight loss. Imaging revealed bilateral pulmonary nodules and areas of consolidation with extensive thoracic and abdominal lymphadenopathy involving the periportal, peripancreatic, retroperitoneal, and portocaval regions, forming conglomerated nodal masses. Given the radiological findings and prior history of antitubercular therapy, disseminated drug-resistant tuberculosis or malignancy was initially suspected. However, microbiological investigations, including bronchoalveolar lavage and endobronchial ultrasound-guided sampling of mediastinal lymph nodes were negative. Endoscopic ultrasound-guided biopsy of abdominal lymph nodes revealed granulomatous lymphadenitis suggestive of sarcoidosis with elevated angiotensin-converting enzyme levels. The patient improved following corticosteroid therapy. This case highlights that conglomerated abdominal lymphadenopathy may represent sarcoidosis and underscores the importance of lymph node morphology in guiding targeted biopsy for diagnosis.