Sarcoidosis in India: practical issues and difficulties in diagnosis and management.

Although sarcoidosis has emerged as an important lung disease in this country, clinicians continue to face difficulties in diagnosis and management of the illness. The relative rarity of sarcoidosis and the remarkable similarity of clinical, radiological and histopathological features with tuberculosis pose problems in the differential diagnosis. Although the pattern and sites of involvement do help, the prevalence of tuberculosis, including those of extrapulmonary sites, is so high that a confident exclusion of the illness is not easy. One important point of difference is the presence of tuberculin-anergy in sarcoidosis vis à vis tuberculosis. Bronchoscopic transbronchial lung biopsy is positive in over 80 percent of patients with sarcoidosis. Exclusion of tuberculosis to diagnose sarcoidosis is important in particular because corticosteroids form the mainstay of treatment for sarcoidosis. Asymptomatic patients with stage I pulmonary and other milder forms of cutaneous sarcoidosis do not need systemic steroid therapy. We have found favorable results with steroid sparing drugs such as methotrexate and azathioprine. Patients with refractory disease, relapse of illness and those with steroid induced complications or concomitant illnesses likely to be worsened by corticosteroids, are mostly treated with weekly, low-dose methotrexate.