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Young M, Goldman-Yassen A, Anderson M, Thakral A, Dutt M, Wolf D, Morris M, Gombolay G. Neurosarcoidosis in children: A systematic review and summary of cases, imaging and management. J Neuroimmunol 2022; 371:577938. [PMID: 35944453 PMCID: PMC9703361 DOI: 10.1016/j.jneuroim.2022.577938] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 07/18/2022] [Accepted: 07/28/2022] [Indexed: 10/16/2022]
Abstract
Neurosarcoidosis is a rare disorder in children. We identified 30 pediatric NS cases through a systematic review. Twenty-one (70%) had systemic sarcoidosis with 30% having primary neurosarcoidosis. Eyes (37%), lymph nodes (37%) and lungs (30%) were most commonly involved. Isolated neurosarcoidosis were more likely in children (30%) than in adults (6%, p = 0.0005). Seizures and optic neuritis were also more common in children than adults (33% vs 14%, p = 0.002; and 30% versus 6%, p = 0.008, respectively). Evaluation, imaging, laboratory findings, and treatments are discussed. Additional research, including multi-center studies, is needed.
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Affiliation(s)
- Morgan Young
- Lincoln Memorial University-DeBusk College of Osteopathic Medicine; 6965 Cumberland Gap Pkwy, Harrogate, TN 37752, USA.
| | - Adam Goldman-Yassen
- Emory University School of Medicine, Departments of Radiology and Imaging Sciences & Pediatrics, and Children's Healthcare of Atlanta, Department of Radiology, 1405 Clifton Road NE, Atlanta, GA, USA.
| | - Monique Anderson
- Department of Neurology, Emory University School of Medicine, 201 Dowman Dr., Atlanta, GA 30322, USA.
| | - Amit Thakral
- Emory University, Children's Healthcare of Atlanta: Pediatrics Institute; Division of Pediatric Rheumatology, 1400 Tullie Road 8(th) Floor, Atlanta, GA 30329, USA.
| | - Monideep Dutt
- Emory University, Children's Healthcare of Atlanta: Pediatrics Institute; Division of Pediatric Neurology, 1400 Tullie Road 8(th) Floor, Atlanta, GA 30329, USA.
| | - David Wolf
- Emory University, Children's Healthcare of Atlanta: Pediatrics Institute; Division of Pediatric Neurology, 1400 Tullie Road 8(th) Floor, Atlanta, GA 30329, USA.
| | - Morgan Morris
- Emory University, Children's Healthcare of Atlanta: Pediatrics Institute; Division of Pediatric Neurology, 1400 Tullie Road 8(th) Floor, Atlanta, GA 30329, USA.
| | - Grace Gombolay
- Emory University, Children's Healthcare of Atlanta: Pediatrics Institute; Division of Pediatric Neurology, 1400 Tullie Road 8(th) Floor, Atlanta, GA 30329, USA.
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Abstract
BACKGROUND Sarcoidosis is an idiopathic, multisystem, inflammatory disease that has central nervous system involvement in 5%-15% of cases. The presentation of neurosarcoidosis is highly variable, and the MRI findings often mimic the appearance of other central nervous system diseases. Therefore, the diagnosis can be challenging. About one-third of neurosarcoidosis cases have neuro-ophthalmic manifestations and, thus, may be evaluated by a neuro-ophthalmologist early in the disease course. METHODS We performed a retrospective review of 22 cases of biopsy-proven sarcoidosis with neuro-ophthalmic manifestations, seen at the Wilmer Eye Institute from January 2013 to September 2019, in which we described the demographic information, clinical presentations, neuroimaging findings, and diagnostic evaluations. RESULTS Twenty-two patients were included. Fifteen patients identified as black and 7 as white. Fifteen were women, and 7 men. Mean age at sarcoidosis diagnosis was 45.9 years (range 26-66). Neuro-ophthalmic findings included optic neuropathy in 11 (50%); proptosis/orbital inflammation in 5 (23%); abducens palsy in 5 (23%); trochlear palsy, trigeminal distribution numbness, and bitemporal hemianopia in 2 each (9%); and oculomotor palsy, facial palsy, optic perineuritis, dorsal midbrain syndrome, central vestibular nystagmus, and papilledema in 1 each (5%). Eight (36%) had a pre-existing diagnosis of sarcoidosis; however, in 14 (64%), the neuro-ophthalmic presentation led to the sarcoidosis diagnosis. Patients with a pre-existing sarcoidosis diagnosis were younger than those without this diagnosis (38.5 vs 50.1 years, P = 0.035). Brain MRI was abnormal in all but 1 case (95%). In patients without a pre-existing sarcoidosis diagnosis, all 7 tested for angiotensin converting enzyme (ACE) had normal values, and 75% of the 12 who had computed tomography (CT) chest had findings suggestive of sarcoidosis (86% of black patients vs 50% of white patients). CONCLUSIONS Patients with neurosarcoidosis may present initially with a neuro-ophthalmic manifestation, and this presentation may be more common in older patients. MRI usually is abnormal, although findings may be nonspecific. Serum testing for ACE is not helpful. Normal CT chest does not rule out underlying sarcoidosis, particularly in white patients.
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Serova NK, Shkarubo AN, Tropinskaya OF, Eliseeva NM, Shishkina LV. [Neurosarcoidosis of the anterior visual pathway (a case report and literature review)]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2019; 83:97-103. [PMID: 31577275 DOI: 10.17116/neiro20198304197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Sarcoidosis is a multisystem granulomatous disorder of unknown nature. Patients often present with pulmonary, skin, eye, and orbital lesions. Involvement of the central nervous system (CNS) is accompanied by granulomatous leptomeningitis and damage to the basal brain structures with formation of granulomas near the cranial nerves, hypothalamus, pituitary gland, cavernous sinuses, optic chiasm, and intracranial optic nerves. The optic nerves can be affected independently of the other CNS regions, which may be the first manifestation of the disease. The article presents two clinical cases of sarcoidosis affecting the anterior visual pathway. Diagnosis of the disease was associated with certain difficulties. A biopsy revealed a sarcoidosis lesion.
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Affiliation(s)
- N K Serova
- Burdenko Neurosurgical Center, Moscow, Russia
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Suresh S, Kosmorsky GS, Lee MS. Isolated optic nerve sarcoidosis. SARCOIDOSIS, VASCULITIS, AND DIFFUSE LUNG DISEASES : OFFICIAL JOURNAL OF WASOG 2017; 34:179-183. [PMID: 32476840 PMCID: PMC7170143 DOI: 10.36141/svdld.v34i2.5410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 08/06/2016] [Indexed: 02/25/2023]
Abstract
Objective: To report three cases of sarcoidosis confined to the optic nerve. Methods: Chart review of clinical, laboratory, imaging, and optic nerve biopsy findings and a review of the literature. Results: All three cases presented with progressive visual loss and showed enhancement of the intraorbital optic nerve on magnetic resonance imaging. There was no evidence for systemic disease, including a negative workup for sarcoidosis or other infiltrative pathologies. Optic nerve biopsy in each case showed non-caseating granulomas consistent with sarcoidosis. Conclusions: Sarcoidosis confined to the optic nerve is a rare phenomenon but should still be considered in the differential diagnosis of progressive optic neuropathy, even in the absence of systemic disease. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 179-183).
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Affiliation(s)
- Sandip Suresh
- University of Minnesota Departments of Ophthalmology
| | | | - Michael S. Lee
- University of Minnesota Departments of Ophthalmology
- and Cole Eye Institute, Cleveland Clinic Foundation
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Rao R, Dimitriades VR, Weimer M, Sandlin C. Neurosarcoidosis in Pediatric Patients: A Case Report and Review of Isolated and Systemic Neurosarcoidosis. Pediatr Neurol 2016; 63:45-52. [PMID: 27524272 DOI: 10.1016/j.pediatrneurol.2016.05.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 05/26/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neurosarcoidosis occurs in fewer than 5% of adults with systemic sarcoid. However, only 53 examples of neurosarcoidosis have been reported in the pediatric population, with nine of those cases being isolated neurosarcoidosis. We present the tenth case of a child with an initial presentation of isolated neurosarcoidosis and a review of the literature. METHODS We searched the Ovid Medline database from 1946 to May 28, 2015. The Mesh terms "neurosarcoidosis," "pediatric," and "child" were exploded, and the Boolean "AND" was used to combine "neurosarcoidosis" with "pediatric" or "child." Articles that were not available in the English language were not included. RESULTS A literature search revealed 53 children with neurosarcoidosis. The most common manifestations included cranial neuropathy (21%), papilledema or optic neuritis (15%), seizures (24.5%), and hypothalamic dysfunction (17%), with the latter two being more likely in younger children. Diagnosis is made by biopsy, but imaging and laboratory tests can aid in diagnosis. Treatment includes corticosteroids or other immunosuppressants. CONCLUSIONS Neurosarcoidosis in children is rare, and our patient is only the tenth child with isolated neurosarcoidosis. These patients highlight the importance of considering a noninfectious diagnosis in the setting of clinical and radiographic findings suggestive of neurosarcoidosis.
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Affiliation(s)
- Rashmi Rao
- Division of Pediatric Neurology, Department of Pediatrics, Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia
| | - Victoria R Dimitriades
- Department of Allergy, Immunology and Rheumatology, Louisiana State University, Baton Rouge, Louisiana
| | - Maria Weimer
- Department of Neurology, Louisiana State University, Baton Rouge, Louisiana
| | - Chelsey Sandlin
- Department of Pediatrics, Louisiana State University, Baton Rouge, Louisiana.
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Anand G, Sin FE, Soilleux E, Chandra J, Piddington K, Quaghebeur G, Wilkinson N, Zaiwalla Z, Kennett R, McShane T. Isolated paediatric neurosarcoidosis presenting as epilepsia partialis continua: a case report and review of literature. Eur J Paediatr Neurol 2013; 17:429-36. [PMID: 23685039 DOI: 10.1016/j.ejpn.2013.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 03/15/2013] [Indexed: 10/26/2022]
Abstract
Isolated paediatric neurosarcoidosis (IPN) is exceptionally rare and only seven cases have been reported so far in the literature. We report the clinical and radiological profile of a 7 year-old boy with epilepsia partialis continua (EPC) who was initially thought to have Acute Disseminated Encephalomyelitis (ADEM), but was subsequently found to have isolated neurosarcoidosis. Additionally, we performed a literature search on Medline and Embase and secondary sources of data such as reference list of articles reviewed. Whilst cranial neuropathy is the commonest presenting feature in adults with neurosarcoidosis, paediatric patients are more likely to present with seizures. Diagnosis presents a clinical challenge as a result of its protean manifestations. Due to its rarity, there remains a lack of evidence base to inform the best choice of treatment for these children. Our patient was successfully treated with a combination of various immunomodulants.
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Affiliation(s)
- Geetha Anand
- Department of Paediatric Neurology, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK.
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Sattelmeyer VM, Vernet O, Janzer R, de Tribolet N. Neurosarcoidosis presenting as an isolated mass of the quadrigeminal plate. J Clin Neurosci 2012; 6:259-61. [PMID: 18639166 DOI: 10.1016/s0967-5868(99)90518-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/1997] [Accepted: 02/02/1998] [Indexed: 10/26/2022]
Abstract
A rare case of neurosarcoidosis presenting as an isolated quadrigeminal plate mass without systemic manifestation of this disease is reported. This 26-year-old man presented with symptoms of acute intracranial hypertension including headache, morning vomiting as well as a right homonymous hemianopsia. Magnetic resonance imaging (MRI) showed an expansive tectal mass causing hydrocephalus secondary to an aqueductal obstruction. An external ventricular drainage was inserted and the mass, postulated to be a glioma, was removed through an occipital transtentorial craniotomy. Histopathological examination revealed numerous sarcoid granulomas. Postoperative course was relevant for bilateral hypoacusis and tinnitus, blurred vision, bilateral palpebral ptosis and bilateral internuclear ophthalmoplegia. Chest X-ray was normal. Postoperative thoracic computed tomography (CT) scan showed mediastinal adenopathies. Lung function tests were normal. Angiotensin converting enzyme (ACE) cerebrospinal fluid (CSF) blood ratio was normal. Postoperative treatment and follow-up included corticosteroids, serial lung function tests and cerebral MRI. Neurosarcoidosis may present with protean clinical manifestations and unusual radiological features. This rare diagnosis has to be kept in mind when facing isolated intracerebral mass lesions.
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Affiliation(s)
- V M Sattelmeyer
- Department of Neurosurgery, Centre Hospitalier Universitaire Vaudois, CH-1011 Lausanne, Switzerland
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Progressive bilateral visual and hearing loss in an elderly woman. J Neuroophthalmol 2010; 30:372-5. [PMID: 21107125 DOI: 10.1097/wno.0b013e3181f50ba2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tsao CY, Lo WD, Rusin JA, Henwood MJ, Boue DR. Isolated neurosarcoidosis presenting as headache and multiple brain and spinal cord lesions mimicking central nervous system metastases. Brain Dev 2007; 29:514-8. [PMID: 17307323 DOI: 10.1016/j.braindev.2006.12.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Revised: 11/27/2006] [Accepted: 12/27/2006] [Indexed: 11/24/2022]
Abstract
Sarcoidosis is uncommon in children. Although isolated neurosarcoidosis has been seen in 15% adults with sarcoidosis, pediatric neurosarcoidosis is rarely reported. Neurosarcoidosis may present with cranial neuropathy, including facial palsy, optic nerve or other cranial nerve involvement, peripheral neuropathy, or manifestations of the central nervous system affecting the hypothalamus, pituitary gland, cerebral cortex, cerebellum, meninges, and spinal cord. The useful diagnostic investigations include magnetic resonance imaging of the brain and spinal cord, cerebrospinal fluid studies, brain and meningeal biopsy if feasible, chest radiography to reveal sarcoidosis, angiotensin-converting enzyme level in the serum or cerebrospinal fluid, and Kveim test when available. We herein report a case of isolated brain biopsy-confirmed neurosarcoidosis in a 17-year-old boy presenting with severe unilateral headache and multiple brain and spinal cord MRI lesions mimicking central nervous system metastases.
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Affiliation(s)
- Chang-Yong Tsao
- Department of Pediatrics and Neurology, The Ohio State University, OH, USA.
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Cem Y, Basar A, Ozlem O, Nilgul Y, Selcuk P. Primary Bilateral Optic Nerve Sarcoidosis. Neuroophthalmology 2005. [DOI: 10.1080/01658100500218038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Frohman LP, Guirgis M, Turbin RE, Bielory L. Sarcoidosis of the Anterior Visual Pathway: 24 New Cases. J Neuroophthalmol 2003; 23:190-7. [PMID: 14504590 DOI: 10.1097/00041327-200309000-00002] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the clinical spectrum and a rational approach to the diagnosis of anterior visual pathway sarcoidosis. METHODS Retrospective chart review of all patients examined in neuro-ophthalmic consultation by 1 author from 1989 to 1998 with a diagnosis of sarcoidosis. RESULTS There were 24 patients (17 female, 7 male, mean age 40 years) with anterior visual pathway sarcoidosis, 17 (71%) of whom were not previously known to have sarcoidosis. Visual acuity ranged from 20/20 to NLP. Normal fundi were observed in 15%. Among the 85% who had fundus abnormalities, pallor was present in 55%, disc edema in 26%, periphlebitis/sheathing in 14%, and optic disc granuloma in 10%. Ten patients (42%) had uveitis, active in only 3 (13%). An elevated angiotensin-converting enzyme (ACE) was present in 16 (76%) of 21 patients tested; evidence of sarcoidosis on chest radiograph was present in 13 (72%) of 18; gallium scanning was abnormal in 13 (93%) of 14; neuroimaging abnormalities of the optic nerves, chiasm, or tract were present in 16 (70%) of 23; lymphocytic pleocytosis or elevated cerebrospinal fluid protein was identified in 14 (88%) of 16 patients, with both values elevated in 7 (44%) patients. Histologic confirmation was obtained in 13 (81%) of 16 who underwent biopsy; in the remaining patients, diagnosis was based entirely on clinical and laboratory evidence. CONCLUSIONS Anterior visual pathway disease may be underrecognized as a presentation of sarcoidosis. Classic fundus findings of periphlebitis and optic granuloma are typically absent. An aggressive diagnostic evaluation may help establish the diagnosis early in its course.
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Affiliation(s)
- Larry P Frohman
- Institute of Ophthalmology and Visual Sciences, UMDNJ-New Jersey Medical School, 90 Bergen Street, Newark, NJ 07103, USA.
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Abstract
Sarcoidosis is a multisystemic disorder characterised by the presence of multiple noncaseating granulomas. Clinically recognisable nervous system involvement occurs in 5-16% of patients with sarcoidosis. However, the incidence of subclinical neurosarcoidosis may be higher. The following article presents a review of the disease, including its pathophysiology, clinical and radiological characteristics and treatment. Neurosarcoidosis should be included in the differential diagnosis of infectious and noninfectious neurological syndromes.
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Affiliation(s)
- F C Vinas
- Department of Neurosurgery, Halifax Medical Center, 311 N Clyde Morris Blvd., Suite 310, Daytona Beach, FL, USA.
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Gass A, Moseley IF. The contribution of magnetic resonance imaging in the differential diagnosis of optic nerve damage. J Neurol Sci 2000; 172 Suppl 1:S17-22. [PMID: 10606800 DOI: 10.1016/s0022-510x(99)00272-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In this paper we review the findings of magnetic resonance imaging (MRI) in optic neuritis and visual dysfunction due to other optic neuropathies. With advances in MRI technology, it has become possible to visualise optic nerve pathology. STIR and RARE sequences, contrast-enhanced sequences, and phased array surface coils are technical developments that provide fine anatomical detail and that are sensitive to pathological changes. MRI can offer information in the differential diagnosis of optic neuropathies, the monitoring of their treatment, and in some instances should provide new insights into the underlying pathophysiological mechanisms.
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Affiliation(s)
- A Gass
- NMR Research Neurology/Radiology, Klinikum Mannheim, University of Heidelberg, Theodor Kutzer Ufer, 68137, Mannheim, Federal Republic of Germany.
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Abstract
The study of critical care issues in pediatric rheumatology is in its infancy, and the available literature is largely case studies and small retrospective series. A child's limited communication skills and the lack of understanding of disease consequences by both parent and child may cause both overuse and underuse of emergency services. To the extent that small case experiences in children with rheumatic diseases do not adequately reflect possible disease presentations or diagnostic and treatment options, pediatric and adult rheumatologists, intensivists, and emergency physicians should readily turn as needed to larger reported experiences in adults with similar conditions.
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Affiliation(s)
- J A Fitch
- Division of Pediatrics, Cleveland Clinic Foundation, Ohio, USA
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