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Yoshimura Y, Kanda-Kikuchi J, Hara T, Sugimoto I. Isolated neurosarcoidosis with a primary lesion in the cauda equina. BMJ Case Rep 2023; 16:e255339. [PMID: 37923332 PMCID: PMC10626903 DOI: 10.1136/bcr-2023-255339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 11/07/2023] Open
Abstract
A man in his late 50s without notable medical background was admitted with subacute onset of bilateral lower extremity weakness. Blood and physiological examinations revealed no significant abnormalities. Cerebrospinal fluid (CSF) examination revealed elevated cell count and protein levels and an immunoglobulin G index of 2.01. T1-weighted MRI showed swelling and enhancement of the cauda equina. After admission, the patient developed bowel and bladder incontinence, deteriorated to manual muscle test 0 and developed right trochlear, trigeminal and facial nerve palsy. He underwent a cauda equina biopsy and was diagnosed with neurosarcoidosis. After methylprednisolone pulse therapy and corticosteroid treatment, cauda equina syndrome including lower extremity weakness and cerebral nerve palsy improved. The patient's daily activities improved to the baseline level over 2 months after discharge. Serum and CSF soluble interleukin-2 receptor levels were within the reference range and decreased with the improvement of neurological and imaging findings.
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Affiliation(s)
- Yusuke Yoshimura
- Department of Neurology, Toranomon Hospital Kajigaya, Kawasaki, Japan
| | | | - Takayuki Hara
- Department of Neurosurgery, Toranomon Hospital, Minato-ku, Japan
| | - Izumi Sugimoto
- Department of Neurology, Toranomon Hospital Kajigaya, Kawasaki, Japan
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Topiwala K, Rath S, Daniel A, Prasad A. Cauda Equina Syndrome in Neurosarcoidosis. Cureus 2020; 12:e10069. [PMID: 33005501 PMCID: PMC7522054 DOI: 10.7759/cureus.10069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Neurosarcoidosis (NS) is a mimicker of many infectious, neoplastic, and inflammatory diseases. It most commonly involves the cranial nerves followed by meninges, ventricles, hypothalamic-pituitary axis, spinal cord, and brainstem/cerebellum. While NS myelopathy has been increasingly recognized, pathophysiological/prognostic and management principles in NS-mediated cauda equina (CE) and conus medullaris (CM) syndromes, which constitute a small and rare minority of this subset, remain elusive. We present the case of a 49 -year-old Hispanic man who developed a peripheral facial palsy and primary hypogonadism within a span of 12 months and eventually got diagnosed with NS after he presented with CE syndrome. We also performed an extensive literature review, with a discussion on the underlying pathophysiology and current management recommendations for NS-mediated CE/CM syndrome. CE/CM syndromes in a middle-aged man should prompt the consideration of NS as a possible differential diagnosis. While steroid responsive, the majority of NS-CE/CM patients are left with residual neurodeficits with quick relapses when steroids are tapered, making the case for early institution of immunosuppressive therapies.
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Affiliation(s)
| | - Subhendu Rath
- Neurology, University of Michigan School of Medicine, Ann Arbor, USA
| | | | - Avinash Prasad
- Neurology, University of Connecticut School of Medicine, Hartford Hospital, Hartford, USA
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Abstract
Neurosarcoidosis occurs in 3% to 10% of patients with sarcoidosis. Cranial neuropathy and meningeal involvement are the most common manifestations, but any part of the nervous system can be affected. Definite diagnosis requires the presence of noncaseating granuloma in the nervous system, although histopathologic confirmation is often not obtainable. Moderate to high dose of glucocorticoids is the main therapy for neurosarcoidosis. Relapse often occurs after the dose of glucocorticoids is tapered down, often necessitating the use of steroid-sparing immunosuppressive agents.
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Affiliation(s)
- Patompong Ungprasert
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic College of Medicine and Science, 200 First Avenue Southwest, Rochester, MN 55905, USA; Division of Rheumatology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Prannok Road, Bangkok 10700, Thailand.
| | - Eric L Matteson
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic College of Medicine and Science, 200 First Avenue Southwest, Rochester, MN 55905, USA; Division of Epidemiology, Department of Health Science Research, Mayo Clinic College of Medicine and Science, 200 First Avenue Southwest, Rochester, MN 55905, USA
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Abstract
Background:Intravascular large cell lymphoma (ILCL) is a diagnostic challenge, with neurological, cutaneous and constitutional symptoms. The natural history is usually an evolution to a comatose state. As invasive procedures are usually required for diagnosis, recognizing the typical clinical pattern is critical since an effective treatment is available.Method:After an extensive literature review of the subject, we report a case of ILCL, analyzing clinical, laboratory, radiological and pathological data. We will also give a special attention to the clinical picture of a conus medullaris (CM) lesion with subsequent encephalopathy in the same patient.Results:We report here a 61-year-old woman with a paraplegia caused by a CM lesion, evolving about one year latter to encephalopathy and eventual coma, with the diagnosis of ILCL confirmed by autopsy. The present case is similar to eight other cases in literature who had CM lesion associated with ILCL, knowing that 80-90% of these patients will eventually evolve to encephalopathy without treatment. Conclusions: ILCL is a recognized but rare cause of coma. Diagnosing it is tremendously important since it is fatal if left untreated. We propose that this specific picture (conus medullaris lesion, eventually evolving to encephalopathy) is quite characteristic and will directly result in better outcome if recognized.
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Nozaki K, Judson MA. Neurosarcoidosis: Clinical manifestations, diagnosis and treatment. Presse Med 2012; 41:e331-48. [PMID: 22595777 DOI: 10.1016/j.lpm.2011.12.017] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2011] [Revised: 12/06/2011] [Accepted: 12/09/2011] [Indexed: 10/28/2022] Open
Abstract
Sarcoidosis is an idiopathic granulomatous disease affecting multiple organs. Neurosarcoidosis, involving the central and/or peripheral nervous systems, is a relatively rare form of sarcoidosis. Its clinical manifestations include cranial neuropathies, meningitis, neuroendocrinological dysfunction, hydrocephalus, seizures, neuropsychiatric symptoms, myelopathy and neuropathies. The diagnosis is problematic, especially when occurring as an isolated form without other organ involvement. Distinguishing neurosarcoidosis from other granulomatous diseases and multiple sclerosis is especially important. Although biopsy of neural tissue is the gold standard for the diagnosis of neurosarcoidosis, this is often not practical and the diagnosis must be inferred though other tests, often coupled with biopsy of extraneural organs. Corticosteroids and other immuno-suppressants are frequently used for the treatment of neurosarcoidosis. This article reviews the epidemiology, pathogenesis, pathology, clinical features, diagnosis, diagnostic tests, diagnostic criteria, and therapy of neurosarcoidosis.
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Affiliation(s)
- Kenkichi Nozaki
- Medical University of South Carolina, Department of Neurosciences, Division of Neurology, Charleston, South Carolina 29425, United States of America.
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Ebner FH, Roser F, Acioly MA, Schoeber W, Tatagiba M. Intramedullary lesions of the conus medullaris: differential diagnosis and surgical management. Neurosurg Rev 2008; 32:287-300; discussion 300-1. [PMID: 18820958 DOI: 10.1007/s10143-008-0173-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2008] [Revised: 08/01/2008] [Accepted: 08/19/2008] [Indexed: 10/21/2022]
Abstract
The medullary conus represents a distinct entity of the spinal cord regarding its anatomical, clinical and microsurgical features. An overview of the pathologic processes of this region is provided. Epidemiological, clinical and neuroradiological characteristics of neoplastic (glial tumors, non-glial tumors, metastasis, primary melanomas) and non-neoplastic lesions (granulomatous lesions, abscess, parasitic infections, vascular, demyelinating and dysembryogenetic lesions) are discussed. Main MR imaging characteristics used to differentiate neoplastic from non-neoplastic lesions consist in pathological spinal cord expansion, gadolinium-enhancement and tumoural cyst formation. Management strategies differ substantially, depending on the kind of lesion. According to the suspected pathological entity radical resection, biopsy or conservative treatments are reasonable options. Intraoperative electrophysiological monitoring is a fundamental part of the surgical setting.
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Affiliation(s)
- Florian H Ebner
- Department of Neurosurgery, Eberhard-Karls-University, Tübingen, Germany.
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Abstract
Although neurosarcoidosis seems to occur in only 5% to 10% of patients who have sarcoidosis, it may lead to significant complications. The diagnosis of neurosarcoidosis usually relies on indirect information from imaging and spinal fluid examination. Although MR imaging remains the most sensitive technique for detecting neurologic disease, other tests, including positron emission tomography scanning and cerebral spinal fluid examination, can provide important information. The role of immunosuppressive agents such as methotrexate, cyclophosphamide, and azathioprine has been expanded, and these agents should be considered for the treatment of some manifestations of neurosarcoidosis. Reports of the antitumor necrosis factor agent infliximab suggest that this drug can be helpful for patients who have neurosarcoidosis.
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Affiliation(s)
- Elyse E Lower
- Interstitial Lung Disease and Sarcoidosis Center, University of Cincinnati Medical Center, 3235 Eden Avenue, Cincinnati, OH 45267, USA.
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Goodman BP, Driver-Dunckley ED, Leslie KO, Patel AC, Wesselius LJ. A case of gait unsteadiness—an atypical manifestation of an unusual disease. Lancet Neurol 2007; 6:1029-32. [DOI: 10.1016/s1474-4422(07)70268-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Shono T, Tamai M, Kobayashi M, Wakasaki H, Furuta H, Nakao T, Hanabusa T, Nishi M, Sasaki H, Nanjo K. Neurosarcoidosis with spinal root pain as the first symptom. Intern Med 2004; 43:873-7. [PMID: 15497529 DOI: 10.2169/internalmedicine.43.873] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a 60-year-old woman with neurosarcoidosis. She was referred to our hospital for examination of the cause of pain in left Th4-6 dermatome. Chest X-ray and computed tomography (CT) revealed bilateral hilar and mediastinal lymphadenopathy, and her serum angiotensin converting enzyme (ACE) level was elevated. Histological finding of mediastinal lymph nodes consisted with sarcoidosis. Therefore, her pain was thought to be spinal root pain caused by neurosarcoidosis. With the administration of prednisolone, her symptom and bilateral hilar lymphadenopathy disappeared, and serum ACE level became normal. It is important to pay attention to neurosarcoidosis when patients show unknown spinal root symptom, although it is rare.
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Affiliation(s)
- Takeshi Shono
- First Department of Medicine, Wakayama Medical University, Wakayama
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Abstract
Sarcoidosis is an inflammatory multisystem disorder of unknown cause. Practically no organ is immune to sarcoidosis; most commonly, in up to 90% of patients, it affects the lungs. The nervous system is involved in 5-15% of patients. Neurosarcoidosis is a serious and commonly devastating complication of sarcoidosis. Clinical diagnosis of neurosarcoidosis depends on the finding of neurological disease in multisystem sarcoidosis. As the disease can present in many different ways without biopsy evidence, solitary nervous-system sarcoidosis is difficult to diagnose. Corticosteroids are the drug of first choice. In addition, several cytotoxic drugs, including methotrexate, have been used to treat sarcoidosis. The value of new drugs such as anti-tumour necrosis factor alpha will be assessed. In this review we describe the clinical manifestations of neurosarcoidosis, diagnostic dilemmas and considerations, and therapy.
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Affiliation(s)
- Elske Hoitsma
- Department of Neurology, Sarcoidosis Management Center, University Hospital Maastricht, Netherlands.
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11
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Abstract
Neurosarcoidosis is a great mimicker. It is often difficult to diagnose particularly when there is no prior history of systemic sarcoidosis. Although certain sites of the neuraxis are more commonly involved than others, any site of the central or peripheral nervous system can be affected. We report a case of sarcoidosis involving the cauda equina in a 38-year-old African American male without prior history of systemic disease. Initial clinical presentation was suggestive of Guillian-Barré syndrome, but the evaluation proved this case to be neurosarcoidosis involving the cauda equina. We have followed this patient for 8 years, and he remains clinically stable on prednisone 5 mg/day.
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Affiliation(s)
- Jagdish R Shah
- 8D, University Health Center, Department of Neurology/Detroit Medical Center, Wayne State University School of Medicine, 4201 St. Antoine, MI 48201, USA.
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Moore FG, Andermann F, Richardson J, Tampieri D, Giaccone R. The role of MRI and nerve root biopsy in the diagnosis of neurosarcoidosis. Can J Neurol Sci 2001; 28:349-53. [PMID: 11766780 DOI: 10.1017/s0317167100001578] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Neurological involvement occurs in 5-15% of patients with sarcoidosis and isolated "neurosarcoidosis" occurs in less than 1% of all cases. Classical clinical presentations have been described, such as bilateral facial palsy, but often the disease presents insidiously with varied signs and symptoms. We present a patient who required biopsy of a lumbar nerve root for diagnosis of chronic, progressive neurosarcoidosis and review the literature with an emphasis on diagnosis. METHODS We have reviewed a patient who presented with signs and symptoms related to infiltration of her meninges and nerve roots by sarcoidosis. All pertinent history and physical information was taken from interviews with the patient and review of her chart. Laboratory, radiographic, and pathological investigations are presented. RESULTS AND CONCLUSIONS A high index of suspicion is required for the diagnosis of neurosarcoidosis. Gadolinium-enhanced MRI is useful but the findings are often nonspecific, and there should be a low threshold for biopsy whenever the diagnosis is considered.
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Affiliation(s)
- F G Moore
- Department of Neurology, Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada
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Bode MK, Tikkakoski T, Tuisku S, Kronqvist E, Tuominen H. Isolated neurosarcoidosis - MR findings and pathologic correlation . A case report. Acta Radiol 2001. [DOI: 10.1034/j.1600-0455.2001.420606.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Hayat GR, Walton TP, Smith KR, Martin DS, Manepalli AN. Solitary intramedullary neurosarcoidosis: role of MRI in early detection. J Neuroimaging 2001; 11:66-70. [PMID: 11198533 DOI: 10.1111/j.1552-6569.2001.tb00014.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Intramedullary neurosarcoidosis may be the first manifestation of the disease and may mimic a tumor clinically and radiographically. Two patients who presented with cervical intramedullary lesions on magnetic resonance imaging (MRI) scans were found to have neurosarcoidosis. CLINICAL PRESENTATION Two patients with negative past medical history presented with progressive myelopathic features, and intramedullary cervical lesions were detected on MRI scan; the diagnosis was made on biopsy of the lesions. Early therapeutic intervention led to a favorable outcome. CONCLUSION Intra-medullary neurosarcoidosis, especially in the cervical cord, can be the initial presentation of the disease, mimicking a tumor. MRI scan, biopsy, and, in fewer cases, angiotensin-converting enzyme levels can help with the diagnosis and may lead to a favorable outcome.
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Affiliation(s)
- G R Hayat
- Department of Neurology, Saint Louis University Health Sciences Center, St. Louis, Missouri, USA
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Abstract
We present three new and 14 retrospective cases of polyradiculopathy in sarcoidosis. Of these, 71% had weakness and 59% areflexia of the lower extremities, and 35% had sphincter dysfunction. Cases often were associated with central nervous system sarcoidosis. All cases involved thoracolumbar or lumbosacral roots, except a single case of cervical polyradiculopathy. Of 14 treated patients, nine improved with corticosteroids, laminectomy, or both. Polyradiculopathy complicating sarcoidosis: (1) is uncommon; (2) primarily involves thoracic and lumbar roots; (3) may arise from contiguous, hematogenous, or gravitational nerve root sleeve seeding; (4) may be asymptomatic; and (5) may improve with corticosteroids. Differential diagnosis of weakness in patients with sarcoidosis should include nerve root involvement from the primary process by direct sarcoid involvement.
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Affiliation(s)
- B Koffman
- Department of Neurology, Henry Ford Hospital and Health Sciences Center, Detroit, Michigan 48202-2689, USA
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