Neurosarcoidosis. Presentation and management

Executive functions in sarcoidosis: a neurocognitive assessment study

Background: Sarcoidosis is a multisystem, inflammatory disease characterized by non-caseating granulomas in multiple organs. Neuropsychological impairment has been told to be present in about 10% of sarcoidosis patients with diagnosed central nervous system (CNS) involvement. Both anatomical lesions and changes in immunological parameters in sarcoidosis may cause cognitive impairment. Based on the information that soluble interleukin-2 receptors (sIL-2R) and tumour necrosis factor alpha (TNF-‱) which plays a role in the pathogenesis of sarcoidosis accumulate in the basal ganglia and prefrontal structures, impairment in executive functioning is most likely to be expected in sarcoidosis. In this study we aimed to evaluate executive functions in sarcoidosis patients. Method: This study included 21 sarcoidosis patients (14 females, 7 males) and 21 healthy controls (12 females, 9 males). All participants were given Beck Depression Inventory-Second Edition, Stroop Test, Verbal Fluency Tests, Digitspan Forward Test, Digitspan Backwards Test and Trail Making Test Part-B. Test results of sarcoidosis patients were compared with healthy controls. Results: No significant difference was detected between sarcoidosis patients and healthy controls by means of neuropsychological assessment tests (p>0.05). Conclusion: Our study showed that sarcoidosis patients did not have impairment in executive functions. This result may be commented in two different outcomes. One of them, would be the probable necessity of additional electrophysiological or radiological tests including detailed paradigmas for evaluation of executive functions. Secondly the effect of therapeutics used in sarcoidosis (steroids and/or immunosuppressants) on cognition should be questioned regarding the controversial previous data which released cognitive decline in sarcoidosis. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 26-34).

Optic neuropathy associated with systemic sarcoidosis

Objective:

To identify and follow a series of 52 patients with optic neuropathy related to sarcoidosis.

Methods:

Prospective observational cohort study.

Results:

The disorder was more common in women and affected a wide age range. It was proportionately more common in African and Caribbean ethnic groups. Two clinical subtypes were identified: the more common was a subacute optic neuropathy resembling optic neuritis; a more slowly progressive optic neuropathy arose in the remaining 17%. Sixteen (31%) were bilateral. Concurrent intraocular inflammation was seen in 36%. Pain arose in only 27% of cases. An optic perineuritis was seen in 2 cases, and predominate involvement of the chiasm in one. MRI findings showed optic nerve involvement in 75% of cases, with adjacent and more widespread inflammation in 31%. Treatment with corticosteroids was helpful in those with an inflammatory optic neuropathy, but not those with mass lesions. Relapse of visual signs arose in 25% of cases, necessitating an increase or escalation of treatment, but relapse was not a poor prognostic factor.

Conclusions:

This is a large prospective study of the clinical characteristics and outcome of treatment in optic neuropathy associated with sarcoidosis. Patients who experience an inflammatory optic neuropathy respond to treatment but may relapse. Those with infiltrative or progressive optic neuropathies improve less well even though the inflammatory disorder responds to therapy.

A case of neurosarcoidosis with labyrinthine involvement

Sarcoidosis is a chronic granulomatous disease of unknown aetiology, which may involve any organ system. It most commonly occurs in adults with childhood involvement being rare. Central nervous system involvement is seen in up to 25% and typically involves meningeal disease resulting in multiple cranial neuropathies. Other common clinical findings include seizures, headache, dementia, and pituitary dysfunction. Imaging plays a central role in the diagnosis with typical findings including pachymeningeal and leptomeningeal enhancing lesions. Other imaging findings include lacunar and major territory infarcts, hypothalamic and infundibular thickening, hydrocephalus, and cranial nerve enhancement. We present a case of an eight-year-old male patient with progressive headache, visual disturbance, unilateral sensory hearing loss, and multiple cranial neuropathies. Imaging findings demonstrated the classic pachymeningeal and leptomeningeal enhancement along much of the skull base, as well as enhancement of the right and left second and eighth cranial nerves. Extensive inflammatory changes were noted in the temporal bones and paranasal sinuses. There was also enhancement of the right and left labyrinths. Sinus biopsy confirmed sarcoidosis. We present the first case to our knowledge of sarcoid labyrinthitis.

A case of neurosarcoidosis that presented with symptoms of Guillain-Barré syndrome

This case report is of a patient who presented with clinical features suggestive of Guillain-Barré syndrome, who on investigation was found to have neurosarcoidosis. The patient was treated with high-dose corticosteroids and physiotherapy and he improved in condition substantially over 1 month. Neurosarcoidosis and its various presentations are discussed in the literature review.

Correlation of MR imaging findings and clinical manifestations in neurosarcoidosis

BACKGROUND AND PURPOSE

MR imaging is widely used for the diagnosis and follow-up of neurosarcoidosis lesions. However, the temporal evolution of imaging abnormalities and the prognostic significance of imaging features is not well understood. We undertook a retrospective study of patients with biopsy-proved or clinically diagnosed neurosarcoidosis for the following reasons: 1) to assess concordance between abnormalities noted on MR imaging with neurologic symptoms at presentation; 2) to correlate changes in imaging findings during follow-up with clinical improvement or worsening; and 3) to identify imaging features that may have prognostic significance.

MATERIALS AND METHODS

We reviewed radiologic records from 1999 to 2008 of patients with biopsy-proved or clinically diagnosed neurosarcoidosis and correlated MR imaging findings in these patients with their demographic characteristics, clinical features, and symptomatic responses during follow-up.

RESULTS

Thirty-two patients were included in the study. Cranial nerve lesions and leptomeningeal disease identified on MR imaging were symptomatic in 64% patients, dural lesions were associated with symptoms in 28% patients, but nonenhancing white matter lesions did not have correlating symptoms. During follow-up, MR imaging findings generally changed in concordance with the change in clinical symptoms (80% patients). Cranial nerve enhancement (9/11) and spinal lesions (5/8) were most likely to resolve with clinical improvement, whereas dural lesions (6/11), enhancing parenchymal lesions (3/7), and non-enhancing parenchymal lesions (0/4) were less likely to change during therapy. Patients with > or =1 enhancing T2-hypointense lesion (4/7, 57%) were less likely to show clinical improvement than those without such lesions (12/13, 92%).

CONCLUSIONS

Although many sarcoid-related MR imaging abnormalities were not associated with correlating symptoms at presentation, there was a high degree of concordance between changes in clinical symptoms and MR imaging abnormalities during follow-up. Enhancing T2-hypointense dural and parenchymal lesions were associated with suboptimal imaging and clinical response to immunosuppressive therapy.

The clinical management of sarcoidosis. A 50-year experience at the Johns Hopkins Hospital

Sarcoidosis is an enigmatic disease with extremely variable manifestations in pattern, severity and course. Since Longcope and Freiman's descriptive monograph in 1952 (50) summarizing the clinical findings of the first half of this century, new dimensions of assessing the disease and treatment have been added. The impact of corticosteroids is central. The present review extends the studies to the second half of this century. Earlier diagnosis is facilitated and treatment often reverses many of the disease manifestations and improves the quality and extent of life for the patient. The management issues and guidelines outlined in this paper for both intrathoracic and extrathoracic disease are based on several longitudinal studies of the sarcoidosis patients summarized here, and 50 years of clinical experience by the senior author (CJJ) at Johns Hopkins Hospital, a tertiary referral center with an active Sarcoid Clinic. Case reports are presented in the appendix. It is clear that corticosteroids are the most effective therapeutic agent for sarcoidosis, usually with impressive and prompt response. This represents the dramatic difference in this disease after 1950. No more specific or effective immunosuppressive or antiinflammatory agents have been identified. Undesirable side effects are minimal if excessive doses are avoided. The effectiveness of "steroid-sparing agents" such as methotrexate is uncertain. Although irreversible tissue damage from the disease may limit the effectiveness of treatment, benefits of corticosteroids greatly exceed the negative side effects. Since spontaneous remissions without treatment do occur, a period of observation of 2 years are more is warranted if the patient is relatively asymptomatic. Gradual radiographic progression for 2 or more years, even without major symptoms or reduction in pulmonary function, indicates the need for a trial of corticosteroid treatment, especially in white patients where symptoms may lag behind the radiographic changes. Relapses as treatment is withdrawn are frequent, especially in African-American patients, who tend to have more severe and more prolonged disease than white patients. A minimum of 1 year of treatment is recommended unless no improvement is noted after 3 months. Continued low-dose prednisone at daily doses of 10-15 mg is helpful in preventing relapses and further progression of disease. Periodic attempts at tapering are justified. Repeated relapses may indicate the need for life-long treatment. When irreversible changes are present, especially in the presence of chronic fibrotic disease, changing goals of treatment to provide optimal supportive care may represent better management than having unrealistic expectations from increased corticosteroid dosage or the addition of other potentially toxic immunosuppressive agents. Many agents related to sarcoidosis require further research. The most important question facing sarcoid researchers today is etiology. It is difficult to design specific therapy when the fundamental causes and disease mechanisms are not established. Rather than being a single disease with a single cause, it is possible that a number of genetic factors and environmental or infectious agents may result in an immune response that is manifested as sarcoidosis. Understanding basic causal mechanisms may help explain the varied disease manifestations and aid in designing curative treatments. Such etiologic questions should be explored from both a basic science and an epidemiologic approach. Therapeutic trials of new drugs such as pentoxyfylline and possibly thalidomide are needed to address their potential as well as limitations of steroid therapy. Finally, for patients who have progressed to organ failure, the problems of sarcoid recurrence in transplanted tissue, increased allograft rejection, and long-term prognosis of solid organ transplants have yet to be resolved. (ABSTRACT TRUNCATED)

Neurosarcoidosis resembling meningioma: MRI characteristics and pathologic correlation

A 37-year-old woman had visual changes. Magnetic resonance imaging showed an extraaxial mass in the anterior clinoid region that was presumed to be meningioma. There was no evidence of systemic or leptomeningeal disease. Pathologic findings were consistent with sarcoidosis. Isolated mass-like neurosarcoidosis, without systemic or leptomeningeal disease is difficult to diagnose preoperatively.

Neurosarcoidosis presenting as hypopituitarism and a cystic pituitary mass

We report a young woman with clinical hypopituitarism and systemic sarcoidosis involving the lung, gastrointestinal tract, and peripheral lymph nodes. Laboratory evaluation confirmed that cortisol, thyroid indices, insulin-like growth factor 1, follicle-stimulating hormone, luteinizing hormone, and estradiol levels were low, with a normal prolactin. Magnetic resonance imaging revealed a large cystic pituitary lesion compressing the optic chiasm and exhibiting rim but not hypothalamic enhancement. The differential diagnosis included cystic macroadenoma, Rathke's cleft cyst, craniopharyngioma, and simple cyst. A transsphenoidal procedure provided decompression and diagnosis: pathology was consistent with sarcoidosis. Postoperatively, the patient's neurosarcoid disease markedly worsened, requiring hypothalamic irradiation. To our knowledge, this is the first report of intracranial sarcoidosis presenting solely as a cystic pituitary mass. An awareness of this possibility is important to prevent inappropriate neurosurgical intervention and subsequent potential exacerbation of neurosarcoidosis.

Neurosarcoidosis presenting as a retroclival mass

A head magnetic resonance imaging scan on a 22-year-old black woman with a 1-year history of brain stem symptoms showed a retroclival mass. Noninvasive studies were unhelpful in characterizing the lesion. Biopsy of the mass showed noncaseating granulomas, consistant with sarcoidosis. Symptoms improved on steroid treatment. Sarcoidosis should be considered in the differential diagnosis of a retroclival mass; difficulties in the noninvasive investigation of neurosarcoidosis are discussed.

Hypothalamic-pituitary sarcoidosis

Patients with sarcoidosis may develop hypopituitarism secondary to granulomatous infiltration of the pituitary and hypothalamus. All degrees of anterior pituitary insufficiency can occur, ranging from selective deficiency to panhypopituitarism; diabetes insipidus occurs frequently. Commonly associated neurologic manifestations are cranial neuropathies, aseptic meningitis, and visual field defects. Although neurologic deficits respond well to corticosteroids, hormonal abnormalities generally persist despite therapy.

Familial myopathy with elevated serum angiotensin-converting enzyme, creatine kinase and lactate dehydrogenase isoenzyme 5

A family is reported in which two members presented with proximal myopathy associated with high serum levels of angiotensin-converting enzyme (SACE), creatine kinase (CK), and lactate dehydrogenase isoenzyme 5. Examination of three relatives revealed elevated SACE levels in all of them, but no myopathy. No evidence of sarcoidosis, the most common disease associated with high SACE levels, could be found. Muscle biopsies of the two affected men revealed myopathic features without granuloma formation. Extensive biochemical, metabolic, immunological, and microbiological studies were all non-contributory. Corticosteroid and, in one patient, azathioprine treatment resulted in an improvement of muscle weakness and in a decrease of SACE as well as CK levels.

Isolated central nervous system granulomatosis resembling sarcoidosis

Isolated central nervous system (CNS) granulomatosis resembling sarcoidosis occurred in a 30-year-old woman who had amenorrhea, ataxia, and obstructive hydrocephalus, and a 9-year course of progressive neurological deterioration with recurrent bouts of diabetes insipidus. Lamellar and nodular meningeal hyalinosis resembling amyloid was noted on an initial brain biopsy. At autopsy, the brain had a non-necrotizing granulomatous meningitis and ventriculitis, most prominent at the base of the brain, including the third ventricle and the hypothalamus, but there were no systemic granulomas.