Medical disclaimer: This page is for educational purposes only. It does not replace the advice of a qualified doctor. Consult Dr. Kunal Waghray or your treating physician for diagnosis and management. Last reviewed May 2026 by Dr. Kunal Waghray, MD DM DNB MNAMS EDRM.
Sarcoidosis Diagnosis in Hyderabad
The referral letter reads: bilateral hilar enlargement on CT, already on anti-TB treatment for three months, no clinical improvement, sputum cultures negative. The patient has been treated for a disease they may not have. Before the first EBUS session is even scheduled, the working diagnosis is already in question.
This is the most common sarcoidosis scenario in Hyderabad: a patient referred for EBUS-TBNA because empirical TB treatment is not working and a tissue diagnosis has never been obtained.
“The most common scenario I see is a patient referred with bilateral hilar enlargement on a chest X-ray, already on anti-TB treatment started empirically. We do the EBUS, sample the nodes, and the histology shows non-caseating granulomas with no AFB. That result means sarcoidosis. Anti-TB drugs do not treat sarcoidosis. These patients need a correct diagnosis before anything else.”
Why Sarcoidosis Is Frequently Misdiagnosed in India
Sarcoidosis is a granulomatous lung disease that produces bilateral hilar lymphadenopathy — enlarged lymph nodes around both lungs on imaging. Tuberculosis produces the same radiological finding. In a country with a high TB burden, the probability of TB is high, and empirical treatment is often started without biopsy confirmation.
This approach works for TB. It does not work for sarcoidosis. The two conditions require entirely different management. TB is treated with a fixed course of anti-mycobacterial drugs. Sarcoidosis, when treatment is needed, is treated with corticosteroids. Anti-TB drugs have no effect on sarcoidosis.
The clues that should prompt a rethink: negative sputum cultures, no clinical improvement after months of treatment, and no epidemiological risk factors for TB. In this setting, a tissue diagnosis is essential.
The Diagnostic Workup for Sarcoidosis
Diagnosis requires three things working together: a compatible clinical and radiological picture, histological evidence of non-caseating granulomas, and exclusion of other causes of granulomatous disease.
Clinical assessment and blood tests
The clinical assessment includes a full history, examination, and review of imaging. Serum ACE (angiotensin-converting enzyme) is measured as a supporting marker — it is elevated in approximately 60 percent of patients with active sarcoidosis. However, it lacks sensitivity and specificity. A normal ACE does not exclude sarcoidosis. Calcium levels, liver function tests, and a full blood count are also checked, as sarcoidosis can affect multiple organ systems.
CT scan of the chest
High-resolution CT characterises the extent and distribution of lymph node enlargement and any pulmonary infiltrates. It also helps stage the disease using the Scadding classification (Stages I–IV) and identifies the most accessible nodes for sampling. In sarcoidosis, lymph nodes are typically bilateral, symmetrical, and hilar or paratracheal in location.
EBUS-TBNA: tissue sampling without surgery
For patients with mediastinal or hilar lymphadenopathy, endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) is the preferred diagnostic procedure. A bronchoscope with an integrated ultrasound probe is passed through the mouth into the airways. The probe visualises lymph nodes adjacent to the airway wall. A needle is passed through the airway wall under real-time ultrasound guidance to sample the node. The samples are sent for cytology, histology, and microbiological culture. EBUS-TBNA has a diagnostic yield of approximately 77 percent for sarcoidosis in published series (PMC4608990), versus 51.5 percent for conventional bronchoscopy without ultrasound guidance.
What the EBUS Biopsy Shows in Sarcoidosis
The histological finding that confirms sarcoidosis is the non-caseating granuloma: a compact cluster of epithelioid macrophages and multinucleated giant cells, without necrosis at the centre. The absence of caseation distinguishes sarcoidosis from TB, where granulomas typically show central necrotic change.
In addition to histology, microbiological cultures are performed on all samples to actively exclude mycobacterial infection. Cultures for Mycobacterium tuberculosis take up to six weeks to return. The clinical decision is usually based on the initial histology result, while cultures run in parallel to confirm exclusion of TB.
Rapid on-site evaluation (ROSE) of cytology smears during the procedure can provide a preliminary result within minutes and helps confirm adequate sampling before the procedure ends.
Confirms sarcoidosis
- Non-caseating granulomas present
- AFB culture negative
- No malignant cells
- Compatible clinical picture
Prompts further investigation
- Caseating granulomas (consider TB)
- Malignant cells (lymphoma or metastasis)
- Non-diagnostic sample (repeat or surgical biopsy)
Löfgren Syndrome: When a Biopsy May Not Be Needed
Löfgren syndrome is a specific clinical presentation of acute sarcoidosis characterised by three features occurring together: erythema nodosum (tender red nodules, usually on the shins), bilateral ankle arthritis or periarthritis, and bilateral hilar lymphadenopathy on chest imaging.
This combination is considered sufficiently specific that international guidelines accept a clinical diagnosis of sarcoidosis without histology when all three features are present. This is the exception: most sarcoidosis presentations require tissue confirmation.
Löfgren syndrome carries an excellent prognosis. The vast majority of patients achieve spontaneous remission within two years. Symptomatic treatment with NSAIDs for the joint and skin manifestations is usually sufficient.
Frequently Asked Questions
Can sarcoidosis be diagnosed without a biopsy?
In most cases, a tissue biopsy is required to confirm sarcoidosis. The diagnosis rests on finding non-caseating granulomas histologically, combined with a compatible clinical and radiological picture, after excluding other causes such as TB. Without histology, the diagnosis is presumptive. Some classic presentations such as Löfgren syndrome (erythema nodosum, bilateral ankle arthritis, and bilateral hilar enlargement) can be diagnosed clinically, but this is the exception rather than the rule.
Why is EBUS preferred over surgical biopsy for sarcoidosis?
EBUS-TBNA reaches mediastinal and hilar lymph nodes through the airway wall under ultrasound guidance, without the need for any incision, general anaesthesia, or hospital admission. Diagnostic yield is high — published data report approximately 77 to 80 percent sensitivity for sarcoidosis with EBUS-TBNA (PMC4608990). Surgical mediastinoscopy, which was previously the gold standard, carries a higher procedural risk and requires general anaesthesia. EBUS has largely replaced surgical sampling for mediastinal and hilar sarcoidosis.
What does the EBUS procedure feel like?
EBUS-TBNA is performed under conscious sedation. Most patients have no memory of the procedure. Mild throat discomfort for a day or two is the most common post-procedure symptom. The procedure typically takes 30 to 45 minutes from start to finish, and patients are usually discharged within a few hours.
How long does it take to get results?
Cytology results from EBUS-TBNA are typically available within three to five working days. Histology (if a tissue core was obtained) may take up to seven days. Microbiological cultures — which are essential to exclude TB — can take up to six weeks for mycobacterial growth. In practice, the clinical decision is usually made on the cytology or histology result, while cultures run in parallel.
Does sarcoidosis always need treatment?
No. Many patients with Stage I or II sarcoidosis are monitored without medication. Approximately 60 to 70 percent of these patients achieve spontaneous remission. Treatment is started when there is progressive lung disease, significant extrapulmonary involvement (particularly cardiac or neurological), or deteriorating lung function. The first-line treatment is oral corticosteroid therapy.
Can sarcoidosis be confused with lymphoma?
Yes. Bilateral mediastinal lymphadenopathy on CT has a broad differential that includes sarcoidosis, TB, lymphoma, and metastatic cancer. EBUS-TBNA is useful precisely because it can sample these nodes and differentiate between these conditions histologically. If the initial EBUS samples are non-diagnostic, repeat sampling or surgical biopsy may be needed.
What is serum ACE and is it useful for sarcoidosis?
Serum ACE (angiotensin-converting enzyme) is produced by epithelioid cells in granulomas and is elevated in approximately 60 percent of patients with active sarcoidosis. However, it is neither sensitive nor specific enough to diagnose or exclude sarcoidosis on its own. Normal ACE does not rule out sarcoidosis, and elevated ACE can occur in TB, lymphoma, and liver disease. It is used as a supplementary marker, not a diagnostic test.
I have been on anti-TB drugs for months with no improvement. Should I be concerned?
Yes, this warrants re-evaluation. Sarcoidosis does not respond to anti-TB therapy. If you have bilateral hilar lymphadenopathy, sputum tests were negative, and your condition has not improved after several months of treatment, the working diagnosis should be reconsidered. A bronchoscopy and EBUS-TBNA to obtain a tissue sample is the appropriate next step.
Book a Sarcoidosis Assessment in Hyderabad
If you have bilateral hilar lymphadenopathy on imaging, if TB treatment has not produced improvement, or if a tissue diagnosis for suspected sarcoidosis has not yet been obtained, the appropriate next step is a bronchoscopy and EBUS-TBNA with a specialist.
Dr. Kunal Waghray, MD DM DNB MNAMS EDRM, performs EBUS-TBNA and full diagnostic bronchoscopy at Respire Airway Clinics in Basheer Bagh and Jubilee Hills, Hyderabad. He provides specialist follow-up for confirmed sarcoidosis cases and coordinates with rheumatologists and ophthalmologists for extrapulmonary disease. To book a consultation, call the clinic directly or use the appointment form on this page.
Clinical References
- EBUS-TBNA vs conventional bronchoscopy for sarcoidosis: diagnostic yield comparison. Respirology. 2015. PMCID: PMC4608990.
- Clinical profile of sarcoidosis: 327 patients, tertiary care centre, India. Lung India. 2022. PMCID: PMC8926222.