Symptoms & Clinical Features

• Pulmonary: Dry cough, dyspnea, chest discomfort (50-80%)
• Systemic: Fatigue, fever, weight loss
• Extrapulmonary: Skin lesions (erythema nodosum, lupus pernio), ocular (uveitis), lymphadenopathy, Neurosarcoid, cardiac sarcoid, hepatic involvement.
• Scadding stages: 0-4 based on CXR appearance
• African presentation: Higher rates of cutaneous and severe pulmonary involvement (Benjelloun et al., 2013; African Health Sciences)

Differential Diagnosis

• Tuberculosis (major differential in endemic regions)
• Fungal infections (histoplasmosis)
• Lymphoma: presenting with bi-halar lymphadenopathy
• Hypersensitivity pneumonitis: with widespread infiltrate on chest radiograph. History of exposure to antigens 
• Berylliosis

Investigations

1. Histology: Non-caseating granulomas on biopsy (transbronchial, skin, lymph node)
2. Radiology: Bilateral hilar lymphadenopathy (BHL), parenchymal infiltrates
3. Laboratory: Elevated ACE (nonspecific), hypercalcemia, abnormal LFTs
4. PFTs: Restrictive pattern with reduced DLCO
   Diagnostic challenge in TB-endemic areas: Need to exclude TB with cultures/PCR before immunosuppression (Okwor et al., 2021)

Treatment

• Asymptomatic Stage I: Observation (60-80% resolve spontaneously)
• Symptomatic/progressive: Corticosteroids (prednisone 20-40mg daily)
• Steroid-sparing: Methotrexate, azathioprine, anti-TNF for refractory cases
• African consideration: Always rule out TB before immunosuppression; monitor for opportunistic infections and prevent reactivation of latent ones.

Follow-up

• 3-6 monthly for active disease, Monitor symptoms, CXR, PFTs, extrapulmonary manifestations
• Screen for complications (pulmonary fibrosis, cardiac, neurosarcoidosis)

Prevention & Control

No known prevention: early diagnosis prevents organ damage through timely treatment

Conclusion and Experience from the clinic

Sarcoidosis in Nigeria is likely underdiagnosed due to TB mimicry. Increased awareness and access to biopsy/histopathology are needed for accurate diagnosis and appropriate management.

In practice, a few numbers of sarcoid patients have been diagnosed with the highest index of suspicion. Chronic cough with non-specific symptoms makes PTB to be the first consideration, others with endobronchial granuloma presenting with wheezing also brought asthma/hyper-reactive airway syndrome into though among others. Flexible bronchoscopy with endobronchial/transbronchial biopsy with BAL and histology with other ancillary investigations have mostly been the illuminating end of the tunnel. Hence, not all that wheeze is asthma, and TB is not the only cause of chronic cough. Early referral to the specialist could prevent life-threatening complications.