Neurosarcoidosis: Pathophysiology, Diagnosis, and Treatment

Neuropsychiatric manifestations of sarcoidosis

BACKGROUND

There has been significant progress in understanding neurosarcoidosis (NS) as a distinct disorder, which encompasses a heterogeneous group of clinical and radiological alterations which can affect patients with systemic sarcoidosis or manifest isolated.

RATIONALE AND AIM OF THE STUDY

The healthcare challenges posed by NS and sarcoidosis in general extend beyond their physical symptoms and can include a variety of psychosocial factors, therefore the recognition of main neuropsychiatric symptoms can be useful to approach patients with NS. Methods: For this purpose, databases such as Pubmed, Medline and Pubmed Central (PMC) have been searched.

RESULTS

A correct diagnosis of NS is established by the combination of clinical picture, imaging features and the histopathological finding of non-caseating and non-necrotizing granulomas. After analyzing the current literature, there is a need for specific, case-control, cohort and clinical trials on the psychiatric manifestations of sarcoidosis, because the evaluation of psychological distress (in terms of emotional suffering e.g. anxiety or depression) is often underestimated.

DISCUSSION AND CONCLUSION

Exploring the neuropsychiatric manifestations of sarcoidosis is useful to raise awareness of this condition among clinicians and to establish a holistic management, which includes both physical and psychological aspects.

Role of soluble biomarkers in treating multiple sclerosis and neuroinflammatory conditions

Multiple sclerosis (MS) is a complex, chronic immune-mediated disease characterized by acute and progressive inflammatory damage of the central nervous system. MS manifests clinically with unpredictable neurological symptoms from focal inflammatory attacks as well as gradual neurodegeneration which contribute significantly to long-term disability progression. As treatment options advance, developing more personalized strategies capture heterogeneous mechanisms of injury which may be targeted or predict outcomes has been a focus of ongoing investigation. The role of soluble biomarkers has emerged as a pivotal tool to assist in these goals. Early promising candidates include neurofilament light chain (NfL) and glial fibrillary acidic protein (GFAP); these intermediate filaments that are expressed in neurons and astrocytes, respectively, are reliably measurable from blood samples and can reveal clinical and subclinical changes, as well as predict progression. Changes in these biomarkers can indicate a response to therapy, thus potentially be used as endpoints in clinical trials. Furthermore, recent research has identified a potential role of these and other soluble biomarkers in other neuroimmunological conditions including neuromyelitis spectrum disorder (NMOSD) and myelin oligodendrocyte glycoprotein associated disease (MOGAD), autoimmune encephalitis, neurosarcoidosis, neuropsychiatric involvement in connective tissue disorders and vasculitides, and a host of neurodegenerative conditions. By integrating biomarker analysis into routine clinical assessments, healthcare providers may move toward a more nuanced and individualized care model, better equipped to meet the challenges posed by these multifaceted diseases. Understanding the dynamics of these biomarkers has many applications that can improve personalized medicine in MS.

Neurosarcoidosis: A Diagnostic Challenge

Neurosarcoidosis when presents with isolated cranial nerve involvement is a significant diagnostic challenge as it can mimic many other conditions like granulomatous infections, vasculitis, IgG4 disease and malignancy. Our patient is a 59 year old lady with symptoms of left sided facial pain, head ache and diplopia. Clinical examination revealed 5th and 6th cranial nerve involvement. MRI revealed enhancing smooth soft tissue lesion in pterygopalatine fossa, pterygomaxillary fissure with extension along V2 and V3. PET-CT revealed hypermetabolic lesion along left mandibular nerve in infratemporal fossa. Vasculitis panel also failed to aid in diagnosis. Biopsy done from the maxillary and mandibular nerve revealed non caseating granuloma which finally led to the diagnosis of Neurosarcoidosis. Presence of non caseasting granuloma in the histopathological examination with absence of infection and malignancy is diagnostic of Neurosarcoidosis. Patient was started on steroids and she improved clinically and symptomatically.

Cranial MRI in neurosarcoidosis: Imaging patterns and nationwide clinical correlations

OBJECT

To investigate cranial MRIs of sarcoidosis pateints by defining typical and atypical findings and their relations with patient characteristics and other disease manifestations.

MATERIALS AND METHODS

A nationwide cohort was formed from patients with an entering ICD-10 code for sarcoidosis twice at least 1 month apart and any tissue biopsy result with the word "granuloma" defined in the biopsy report were considered to have sarcoidosis. Data regarding patients were obtained by using Turkish Ministry of Health National Electronic Data base. Patients of the formed cohort were investigated for the presence of a cranial imaging at any time.

RESULTS

4367 patients were defined as sarcoidosis and enrolled in the study. 1659 cranial imagings in 689 patients were investigated. 1175 imagings were deemed suitable and evaluated. 3.4% of the patients had findings suggestive of sarcoidosis. Most common lesions were leptomeningeal or dural thickening with/without contrast material enhancement and midbrain/brainstem lesions. Presence of pulmonary sarcoidosis was the only significant factor with a negative predictive effect for patients to have typical findings.

DISCUSSION

Among sarcoidosis patients with MRI we detected 3.4% of them had findings suggestive of CNS sarcoidosis. Absence of pulmonary involvement was observed to be predictor for occurrence of typical manifestations.

Imaging in sarcoid disease

Sarcoidosis is a complex multisystem inflammatory disease characterized by noncaseating granulomas and variable clinical manifestations, most commonly affecting the lungs, skin, heart, and nervous system. Imaging is central in its diagnosis, staging, and management, providing essential insights into organ involvement and disease activity. Pulmonary manifestations remain the hallmark, with modalities such as high-resolution chest computed tomography (CT) and chest radiography offering critical diagnostic clues. Imaging techniques, including Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) and cardiac magnetic resonance imaging, are invaluable for identifying cardiac and systemic involvement, including cutaneous and musculoskeletal, while abdominal MRI and ultrasound help delineate hepatic and splenic manifestations. Neurosarcoidosis requires MRI for precise evaluation, supplemented by FDG-PET to guide biopsy and monitor treatment response. This chapter synthesizes the imaging features of sarcoidosis across organ systems, emphasizing practical approaches to diagnosis and management while identifying key areas for future research.

Sarcoidosis presenting as a suspected metastasis around the optic disc

We present a case of systemic sarcoidosis presenting with mild blurred vision, limitation of left eye movements and choroidal infiltration around the left optic disc. Symptoms and signs of inflammation were absent, and secondary malignancy was suspected. After a prolonged series of investigations revealed multiple asymptomatic inflammatory lesions, subsequent lymph node biopsy revealed non-caseating granulomas. This case highlights the protean manifestations of sarcoidosis and the sophisticated investigations that may be required to diagnose it.

Neurosarcoidosis complicated by systemic vasculitis

A 62-year-old woman with medical history of hypertension, diabetes mellitus, coronaropathy, neurosarcoidosis, s/p craniotomy (brain mass resection) presented with worsening headaches, generalized weakness, vomiting, and hyporexia over two weeks. Brain MRI showed worsening of the known right cavernous sinus mass, vasculitis panel was negative. Patient received IV steroids; during hospitalization, she had a syncopal episode, CT Head was normal, EKG showed new T-wave inversion with troponin elevation. She experienced worsening mentation, left-sided hemiparesis; CT head showed acute hypodensity in the right MCA territory, CTA revealed bilateral distal M1 segment stenosis. Ineligible for thrombolysis/thrombectomy, she was started on aspirin. Echocardiograms were normal. Ischemic signs in her right toes prompted an aortogram showing arterial obstructions in the RLE, necessitating SFA stent placement, and clopidogrel. IV cyclophosphamide was added without additional vascular complications. This case illustrates neurosarcoidosis complicated by systemic vasculitis of medium-large vessels, responding to aggressive immunosuppression with glucocorticoids and cytotoxic agents.

Sarcoidosis: molecular mechanisms and therapeutic strategies

Sarcoidosis, a multisystemic granulomatous disease with unknown etiology, is characterized by formation of noncaseating granulomas, which can affect all organs. Recent studies have made outstanding achievement in understanding the pathology, etiology, genetics, and immune dysregulation involved in granuloma formation of sarcoidosis. Antigen stimulation in genetically predisposed individuals enhances the phagocytic activity of antigen-presenting cells, including macrophages and dendritic cells. CD4 + T cells initiate dysregulated immune responses and secrete significant quantities of inflammatory cytokines, including interleukin (IL)-2 and interferon-gamma (IFN-γ), which play a crucial role in modulating the aggregation and fusion of macrophages to form granulomas. The current therapeutic strategies focus on blocking the formation and spread of granulomas to protect organ function and alleviate symptoms. The efficacy of traditional treatments, such as glucocorticoids and immunosuppressants, has been confirmed in the management of sarcoidosis. Promising therapeutic agents encompass inhibitors of cytokines, like those targeting tumor necrosis factor (TNF)-α, as well as inhibitors of signaling pathways, such as Janus kinase (JAK) inhibitors, which exhibit favorable prospects for application. Although there has been progress in the identification of biomarkers for the diagnosis, prognosis, activity and severity of sarcoidosis, specific and sensitive biomarkers have yet to be identified. This review outlines recent advancements in the molecular mechanisms and therapeutic strategies for the sarcoidosis.

The Value of the "Trident Sign" and Flow Cytometry in Suspecting Spinal Cord Sarcoidosis: A Case Report and a Flow Chart of Diagnostic Imaging in Longitudinally Extensive Transverse Myelitis (LETM)

The diagnosis of sarcoidosis-related longitudinally extensive transverse myelitis (LETM) is challenging, requiring the exclusion of mimicking conditions along with histopathological confirmation of the diseases affecting the spinal cord. This report presents the case of a 68-year-old woman with complaints of low back pain and tingling dysesthesia in the limbs one month prior and finally developed paraparesis with the need for support from a third person for walking. Magnetic resonance imaging (MRI) of both the brain and spinal cord, total body computed tomography, lumbar puncture, flow cytometry of the cell sediment from cerebrospinal fluid (CSF), and whole-body 18-F-fluorodeoxyglucose positron emitting tomography (FDG-PET) assisted us to finalise the diagnosis. The presence of the "trident sign" in axial sequences of MRI is of exceptional value since it is a clue for sarcoidosis of the spinal cord. CSF flow cytometry may help clinicians to rule out lymphoma, and FDG-PET can help clinicians in identifying manifestations of sarcoidosis, which need to be biopsied so as to unveil the final diagnosis.

Cerebral vasculitis related to neurosarcoidosis: a case series and systematic literature review

Cerebral vasculitis is a rare but severe manifestation of neurosarcoidosis (NS) that has received little attention. The aim of the present study was to characterize clinical and diagnostic features as well as potential treatment strategies of cerebral vasculitis related to NS. We assessed 29 patients with cerebral vasculitis related to NS (15 female, mean age at time of diagnosis 45 years, SD = 11.85) among these were four new cases from our hospital records and 25 previously published cases from a systematic literature review. The demographic, clinical, and diagnostic features of those 29 patients with cerebral vasculitis related to NS were compared with a group of 73 NS patients without vasculitic involvement (37 female, mean age at time of diagnosis 47 years, SD = 14.79). Neurologic deficits and MRI abnormalities were significantly more frequent in cerebral vasculitis related to NS than in NS without vasculitic involvement. Patients with cerebral vasculitis related to NS significantly more often presented with headache, motor symptoms, and cognitive and/or behavioral changes. Non-neurologic manifestations of sarcoidosis did not significantly differ in character or frequency between both groups. Glucocorticoids in combination with methotrexate, cyclophosphamide, or infliximab were the most frequently used treatment strategies in cerebral vasculitis related to NS. Within the complex diagnostic work-up that is required in cerebral vasculitis related to NS sufficient angiographic imaging as digital subtraction angiography or MRI vessel wall imaging and tissue biopsy are of particular significance as they can detect vascular changes caused by inflammatory processes.

Diagnostic and Therapeutic Insights Into Pediatric Neurosarcoidosis: Observations From French Pediatric Rheumatology Centers

BACKGROUND

The diagnosis and management of neurosarcoidosis (NS) in pediatric patients remain challenging, with limited case documentation to guide clinicians. Most existing reports focus on initial presentations. This study aimed to outline the clinical features, management, and medium-term outcomes of pediatric NS METHODS: In this retrospective, multicentric, observational study, we collected data from pediatric patients followed in French pediatric rheumatology centers with a diagnosis of NS between January 2001 and June 2023.

RESULTS

We identified 11 patients diagnosed with NS, comprising eight girls and three boys. The mean age at diagnosis of sarcoidosis was 10 (5 to 15) years, and the mean age of diagnosis of NS was 11.5 (5 to 17) years. Predominant neurological symptoms included headache (nine of 11 patients), papilledema (6 of 11 patients), facial palsy (two patients), seizures (one patient), and motor deficit (two patients). Nine of 11 patients had eye involvement, which consisted of granulomatous and bilateral uveitis. All patients exhibited meningitis, with cerebrospinal fluid white blood cell counts ranging from 6 to 70 cells/mm3. Six individuals presented neurological abnormalities on imaging, detailed in this study. Treatment primarily involved corticosteroids, methotrexate, and tumor necrosis factor alpha (TNF-alpha) inhibitors. Biologics targeting TNF-alpha were necessary to achieve remission in eight of 11 patients. In two patients who did not receive this treatment initially, it was required later in the course of evolution.

CONCLUSIONS

This study enhances understanding of the clinical course of pediatric NS and supports the early use of TNF-alpha biologics for improved management in affected children.

From Diagnosis to Emergency: Mediastinal Abscess After Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in a Patient With Sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown etiology, primarily affecting the lungs and the lymphatic system. Its diagnosis is challenging, and in many cases, it requires histopathological confirmation through the identification of non-caseating granulomas. The presented case illustrates its diagnostic complexity and highlights a rare, delayed complication associated with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). The patient developed a mediastinal abscess, a serious and uncommon post-procedural event, which likely resulted from microperforation of the bronchial wall during the aspiration. Symptoms developed several days after the procedure, with fever, chest pain, and signs of mediastinal infection. This case emphasizes the need for heightened clinical awareness and careful monitoring following EBUS-TBNA.

A framework for exclusion of alternative diagnoses in sarcoidosis

Sarcoidosis is a multisystem granulomatous syndrome that arises from a persistent immune response to a triggering antigen(s). There is no "gold standard" test or algorithm for the diagnosis of sarcoidosis, making the diagnosis one of exclusion. The presentation of the disease varies substantially between individuals, in both the number of organs involved, and the manifestations seen in individual organs. These qualities dictate that health care providers diagnosing sarcoidosis must consider a wide range of possible alternative diagnoses, from across a range of presentations and medical specialties (infectious, inflammatory, cardiac, neurologic). Current guideline-based diagnosis of sarcoidosis recommends fulfillment of three criteria: 1) compatible clinical presentation and/or imaging 2) demonstration of granulomatous inflammation by biopsy (when possible) and, 3) exclusion of alternative causes, but do not provide guidance on standardized strategies for exclusion of alternative diagnoses. In this review, we provide a summary of the most common differential diagnoses for sarcoidosis involvement of lung, eye, skin, central nervous system, heart, liver, and kidney. We then propose a framework for testing to exclude alternative diagnoses based on pretest probability of sarcoidosis, defined as high (typical findings with sarcoidosis involvement confirmed in another organ), moderate (typical findings in a single organ), or low (atypical/findings suggesting of an alternative diagnosis). This work highlights the need for informed and careful exclusion of alternative diagnoses in sarcoidosis.

Chronic Sarcoidosis: Diagnostic Difficulties and Search for New Criteria of Inflammatory Activity (A Case Report and Literature Review)

Sarcoidosis is a systemic inflammatory disease with an unknown etiology and a wide range of clinical manifestations. The incidence of sarcoidosis ranges from approximately 1 to 15 cases per 100,000 individuals per year worldwide. The significant variability in clinical presentations and target organs, as well as concomitant diseases, greatly complicates diagnosis. We analyzed articles in PubMed, Scopus, Cochrane Library, and Embase, where databases were searched using the keywords "chronic sarcoidosis", "diagnosis of sarcoidosis", "course of sarcoidosis", "pulmonary sarcoidosis", "cardiac sarcoidosis", "skin sarcoidosis", "neurosarcoidosis", "ocular sarcoidosis", and "autoimmune inflammation". Studies on the course and diagnosis of sarcoidosis with a deep search of ten years were included. In this review, we present an analysis of publications on the course and diagnosis of chronic sarcoidosis, as well as a clinical case. We have noted that the diagnosis of chronic sarcoidosis is particularly difficult due to the lack of specific biomarkers or their combination. The development and introduction of new diagnostic criteria for this disease will contribute to increasing the level of efficiency, not only of the diagnostic complex, but also the prognosis of the development and course of the pathological process. Conclusion: For the most accurate diagnosis and determination of prognosis, the existence of a single immunological or imaging marker with sufficient sensitivity and specificity is necessary.

Pearls & Oy-sters: Vocal Cord Palsy as the Presenting Manifestation of Neurosarcoidosis

Neurosarcoidosis poses a significant diagnostic challenge due to the diversity of presenting symptoms. We report a case of a 64-year-old woman with a history of hypertension and diabetes who presented with 3 weeks of progressive dysphonia and dysphagia. Initial differential diagnosis included myasthenia gravis, Guillain-Barré syndrome, infections such as syphilis or HIV, and neurosarcoidosis. Laryngoscopy and EMG demonstrated cranial nerve X and XII palsy. MRI brain was unrevealing, but a CT of the head and neck showed radiologic evidence of left vocal cord paralysis and asymmetric prominence of the left lingual tonsillar tissue. Her clinical findings, elevated CSF-ACE (angiotensin-converting enzyme) and CSF sIL-2R (soluble interleukin-2 receptor), and a previous thoracic tissue biopsy showing granulomas led to a 'probable' diagnosis of neurosarcoidosis after the thorough exclusion of other diagnoses. The patient was treated with pulse steroids and outpatient initiation of infliximab. There was prompt improvement in dysphagia and gradual amelioration of dysarthria and dysphonia. This case illustrates cranial nerve X and XII palsy as the presentation of neurosarcoidosis. In addition, it demonstrates the value of CSF sIL-2R as a biomarker for neurosarcoidosis and highlights the growing popularity of using steroid-sparing agents for treatment to achieve better outcomes with fewer side effects.

Neurosarcoidosis Presenting With Diffuse Multinodular Pachymeningeal Enhancement in the Cervicothoracic Spine: A Case Report and Review of the Literature

Neurosarcoidosis, particularly in the absence of extra-neurologic systemic manifestations of sarcoidosis, is a challenging diagnosis that has a wide array of presentations. Most often presenting with cranial neuropathies, basilar meningitis or pituitary/hypothalamic dysfunction, isolated involvement of the spinal cord without cranial manifestations is exceptionally rare, often involving intramedullary lesions. Here, we present the unique case of a 64-year-old female with atypical neurosarcoidosis presenting with myelopathy from extra-dural nodules without other neurologic or systemic symptoms. Pathology results from the extra-dural nodules were consistent with a neurosarcoidosis diagnosis. This is the first case report in the literature to our knowledge of atypical neurosarcoidosis presenting as isolated intradural extramedullary nodules without cranial or systemic manifestations of sarcoid disease.

Glial Fibrillary Acidic Protein Astrocytopathy: Review of Pathogenesis, Imaging Features, and Radiographic Mimics

Glial fibrillary acidic protein (GFAP) astrocytopathy is a recently described autoimmune inflammatory disorder of the CNS characterized by the presence of specific antibodies targeting the intracellular filament protein in mature astrocytes. The pathogenesis is heterogeneous and poorly understood, with around 20%-34% of cases occurring as a paraneoplastic syndrome, most frequently associated with ovarian teratomas. It presents clinically as acute or subacute encephalomyelitis, and the diagnosis relies on imaging and detection of GFAP-Immunoglobulin (GFAP-IgG) in the CSF. Characteristic imaging findings include linear perivascular enhancement in the white matter extending in a radial pattern. Other imaging findings include periependymal enhancement, longitudinally extensive cord signal changes, intramedullary enhancement, optic neuritis, and papillitis. There is significant imaging overlap with other neuroinflammatory diseases like neuromyelitis optica spectrum disorder and lymphoproliferative conditions. GFAP astrocytopathy is characteristically responsive to steroids with, however, a significant rate of relapse. Currently, literature on this novel entity is limited with no established diagnostic criteria or standard treatment regimen. This comprehensive review explores the clinical, radiographic, and histopathologic aspects of GFAP astrocytopathy, shedding light on its complex nature and potential diagnostic challenges. The paper highlights the neuroimaging findings with a focus on differentiating GFAP astrocytopathy from other neuroinflammatory disorders.

Differential diagnosis of suspected multiple sclerosis: considerations in people from minority ethnic and racial backgrounds in North America, northern Europe, and Australasia

The differential diagnosis of suspected multiple sclerosis has been developed using data from North America, northern Europe, and Australasia, with a focus on White populations. People from minority ethnic and racial backgrounds in regions where prevalence of multiple sclerosis is high are more often negatively affected by social determinants of health, compared with White people in these regions. A better understanding of changing demographics, the clinical characteristics of people from minority ethnic or racial backgrounds, and the social challenges they face might facilitate equitable clinical approaches when considering a diagnosis of multiple sclerosis. Neuromyelitis optica, systemic lupus erythematous, neurosarcoidosis, infections, and cerebrovascular conditions (eg, hypertension) should be considered in the differential diagnosis of multiple sclerosis for people from minority ethnic and racial backgrounds in North America, northern Europe, and Australasia. The diagnosis of multiple sclerosis in people from a minority ethnic or racial background in these regions requires a comprehensive approach that considers the complex interplay of immigration, diagnostic inequity, and social determinants of health.

Cerebrospinal Fluid Cytokine and Chemokine Profiles in Central Nervous System Sarcoidosis: Diagnostic and Immunopathologic Insights

OBJECTIVE

To evaluate the cerebrospinal fluid (CSF) cytokine/chemokine profile of central nervous system (CNS) neurosarcoidosis (NS), and its utility in differential diagnosis, treatment, and prognostication.

METHODS

In this case-control study, we validated 17 cytokines/chemokines (interleukin [IL]-1-beta, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12p70, IL-13, IL-17A, BAFF, IL-8/CXCL8, CXCL9, CXCL10, CXCL13, GM-CSF, interferon-gamma, and tumor necrosis factor [TNF]-alpha) in a multiplexed automated immunoassay system (ELLA; Bio-Techne, Minneapolis, MN, USA), and assessed them in CSF and serum of symptomatic patients with probable or definite CNS NS (01/2011-02/2023) with gadolinium enhancement and/or CSF pleocytosis. Patients with multiple sclerosis, primary CNS lymphoma, aquaporin-4 immunoglobulin G positivity, non-inflammatory disorders, and healthy individuals were used as controls.

RESULTS

A total of 32 NS patients (59% women; median age, 59 years [19-81]) were included; concurrent sera were available in 12. CSF controls consisted of 26 multiple sclerosis, 8 primary CNS lymphoma, 84 aquaporin-4 immunoglobulin G positive, and 34 patients with non-inflammatory disorders. Gadolinium enhancement was present in 31 of 32 NS patients, and CSF pleocytosis in 27 of 32 (84%). CSF IL-2, IL-6, IL-10, IL-13, BAFF, IL-8/CXCL8, CXCL9, CXCL10, CXCL13, GM-CSF, interferon-gamma, and TNF-alpha levels were significantly higher in NS patients compared with non-inflammatory controls (p ≤ 0.02); elevations were more common in CSF than serum. Concurrent elevation of IL-6, CXCL9, CXCL10, GM-CSF, interferon-gamma, and TNF-alpha was present in 18 of 32 NS patients, but only in 1 control. Elevated IL-6, IL-10, IL-13, CXCL9, CXL10, GM-CSF, and TNF-alpha associated with measures of disease activity.

INTERPRETATION

NS CSF cytokine/chemokine profiles suggest T cell (mainly T helper cell type 1), macrophage, and B-cell involvement. These signatures aid in NS diagnosis, indicate disease activity, and suggest therapeutic avenues. ANN NEUROL 2024;96:704-714.

[Position paper of the Austrian Society for Rheumatology and the Austrian Society for Pneumology on the diagnosis and treatment of sarcoidosis 2024]

In many cases sarcoidosis is a multisystemic disease that requires interdisciplinary medical cooperation in the diagnostics, treatment and medical care during follow-up. Due to the often chronic course, it is of utmost importance to include patients with their priorities and wishes at an early stage and extensively in disease management and to establish a shared decision making whenever possible. In the process of writing this joint position paper, the expert group on interstitial and orphan lung diseases of the Austrian Society for Pulmonology and the working group on rheumatological lung disorders of the Austrian Society for Rheumatology and Rehabilitation sought to include patient advocacy groups as well as experts for rare organ manifestations of sarcoidosis. This position paper is not only meant to reflect current scientific and clinical standards but should also focus the national expertise and by networking and exchange to be a first step to strengthen cooperation between stakeholders to ultimately improve care for patients with sarcoidosis.

Ways to think about vasculitic neuropathy

PURPOSE OF REVIEW

Vasculitis as a pathomechanism for neuropathy can be isolated to the peripheral nervous system, a part of a systemic autoimmune condition or a component of another syndrome. This review aims to discuss the broad range of diagnoses in which vasculitic neuropathy can be encountered, highlight the progress in imaging techniques in identifying vasculitis, and the new drugs developed for other autoimmune diseases that may be applied to neurological conditions.

RECENT FINDINGS

Advances in imaging modalities, ultrasound, MRI and FDG-PET scanning for neuromuscular applications has redefined many aspects of vasculitic neuropathies. The benefit of dividing vasculitides by vessel size is becoming less absolute as diagnostic approaches advance. MRI and FDG-PET are widely used in diagnosis, defining extent of involvement of disease and monitoring. In neuralgic amyotrophy, the identification of hourglass-like constrictions on imaging has changed the treatment paradigm to include surgical interventions. These diagnostic approaches are supported by new immunomodulating and immunosuppression techniques.

SUMMARY

Vasculitic neuropathies are a broad group of conditions with a range of causes and associations. Increased use of imaging techniques impacts our traditional definitions and classifications. The growth in treatment options for other autoimmune conditions are likely to infiltrate the neurological landscape.

Neurosarcoidosis in a 67-Year-Old Male Without Pulmonary Involvement: A Case Report

Neurosarcoidosis is a rare and complex form of sarcoidosis that affects the nervous system, presenting significant diagnostic and therapeutic challenges due to its varied neurological symptoms and potential complications. We present a case of a 67-year-old immunocompetent male who presented with altered sensorium, prompting a thorough evaluation. His medical history revealed intermittent low-grade fevers, progressive weight loss, and frailty, rendering him bedridden for over a year. Previous blood tests had ruled out specific etiologies, with normal serum calcium and angiotensin-converting enzyme (ACE) levels. Upon presentation, further diagnostic workup included imaging and laboratory tests. Results showed elevated serum calcium, increased ACE levels, and depressed intact parathyroid hormone levels. MRI of the brain with contrast revealed lobulated mucosal thickening in the right sphenoid sinus and adjacent anterior cavernous sinus. A CT scan of the chest was unremarkable. Additionally, a splenic biopsy revealed hypoechoic foci with neutrophilic, lymphocytic, and histiocytic granulomas. Based on imaging and histopathological findings, the patient was diagnosed with neurosarcoidosis. The patient was treated with prednisolone and methotrexate, leading to a prompt improvement in consciousness and symptoms. Follow-up demonstrated continued improvement and stabilization of his condition. This case highlights the importance of considering neurosarcoidosis in patients with unexplained neurological symptoms and underscores the value of a multidisciplinary approach in managing this challenging condition.

Neurosarcoidosis: Current Perspectives on Diagnosis, Management, and Future Directions

Neurosarcoidosis, a manifestation of sarcoidosis affecting the central or peripheral nervous system, presents unique challenges in diagnosis and management. Neurosarcoidosis can manifest with a wide range of symptoms, including cranial neuropathies, seizures, meningitis, and cognitive impairments. The heterogeneity of presentations often leads to diagnostic delays and complications. Diagnosis relies on a combination of clinical features, neuroimaging, cerebrospinal fluid analysis, and evidence of systemic sarcoidosis. Recent advances in imaging techniques, including high-resolution MRI, positron emission tomography (PET) scans, and novel biomarkers, have improved diagnostic accuracy. However, distinguishing neurosarcoidosis from mimicking conditions such as multiple sclerosis remains challenging. Treatment typically begins with corticosteroids, often requiring long-term immunosuppression. Second-line agents such as methotrexate and mycophenolate mofetil are frequently used as steroid-sparing options. Biologic therapies, particularly Tumor necrosis factor-alpha (TNF-α) inhibitors like infliximab, have shown promise in refractory cases. The long-term management of neurosarcoidosis necessitates a multidisciplinary approach with regular monitoring of disease activity and treatment response. Despite advancements, significant knowledge gaps persist in understanding the etiology, pathophysiology, and optimal management of neurosarcoidosis. Future research directions include identifying specific biomarkers, developing targeted therapies, and exploring novel imaging techniques. The rarity and heterogeneity of neurosarcoidosis underscore the importance of multicenter studies and international collaborations to advance our understanding and improve patient outcomes. Emerging technologies and innovative therapeutic approaches offer promising avenues for enhancing diagnosis and treatment in the coming years.

Radiological features of patients with headache as a presenting symptom of neurosarcoidosis

OBJECTIVE

To describe the radiological features of patients with headache as a presenting symptom of neurosarcoidosis.

BACKGROUND

Neurologic complications occur in approximately 5%-10% of patients with sarcoidosis, and approximately 50% of these patients have neurologic deficits at the time sarcoidosis is first diagnosed. A wide spectrum of central and peripheral nervous system clinical manifestations may be observed, including cranial nerve palsies, sensory and/or motor deficits, and headache. Magnetic resonance imaging (MRI) results in patients with neurosarcoidosis may include abnormal contrast enhancement, structural masses, and demyelinating lesions.

METHODS

This single-center retrospective cohort study assessed patients who were diagnosed with neurosarcoidosis in an urban tertiary care center between 1995 and 2016. We included patients who had MRI results at the time of diagnosis. Patients were divided into two groups based on the presence or absence of headache as a presenting symptom. The MRI result of meningeal contrast enhancement was reviewed.

RESULTS

Of the 110 patients analyzed, 30 (27.3%) had an initial presenting symptom of headache while 80 (72.7%) did not. Patients with headache had a higher proportion of meningeal contrast enhancement on MRI (66.7% [20/30] vs. 25.0% [20/80]; p < 0.001) and leptomeningeal involvement (53.3% [16/30] vs. 7.5% [6/80], p < 0.001) compared to patients with no headache. However, those with headache had a lower proportion of spinal cord localization (13.8% [4/29] vs. 34.2% [26/76], p = 0.038) and intraparenchymal central nervous system involvement (16.7% [5/30] vs. 51.3% [41/80], p = 0.001) compared to patients with no headache.

CONCLUSION

Patients with neurosarcoidosis who presented with headache as an initial symptom had a higher proportion of meningeal contrast enhancement seen by MRI than patients who presented with other neurological symptoms. This suggests a clinico-radiologic link between headache and meningeal disruption in patients with neurosarcoidosis.

Looking beyond blurred margins

A 60-year-old man presented to an outside ophthalmology clinic with 1 month of progressive vision loss in the right eye (OD). Right optic disc edema was noted. Brain and orbit magnetic resonance imaging revealed right optic nerve and left occipital lobe enhancement. He was seen initially by neurology and neurosurgery and subsequently referred to neuro-ophthalmology for consideration of optic nerve biopsy. He was seen 3 months after his initial symptom onset where vision was light perception OD and a relative afferent pupillary defect with optic nerve edema. OS was unremarkable. A lumbar puncture with flow cytometry was negative for multiple sclerosis and lymphoma. At his oculoplastic evaluation for optic nerve biopsy, his vision was noted to be no light perception OD. Optic nerve biopsy demonstrated non-caseating granulomatous inflammation consistent with neurosarcoidosis. The patient was started on high-dose oral steroids with improvement of disc edema, as well as significant improvement in optic nerve and intracranial parenchymal enhancement, although his vision never improved.

Neurosarcoidosis Complicated by Noncommunicating Hydrocephalus with Atypical Presentation, Diagnosed and Treated with Endoscopic Surgery: A Case Report

Neurosarcoidosis is a condition that is characterized by the occurrence of noncaseating epithelioid granulomas in various organs throughout the body, including the lungs, heart, and central nervous system. It is particularly prevalent in cases of noncommunicating hydrocephalus. While its clinical presentations may vary, neurological deficits such as hemiparesis are extremely uncommon. We herein present a case of unilateral hydrocephalus resulting from neurosarcoidosis presenting with hemiparesis. A 58-year-old woman exhibited right hemiparesis, altered mental status, and aphasia persisting for 1 month. Magnetic resonance imaging showed unilateral hydrocephalus of uncertain etiology. The patient underwent external ventricular drainage, endoscopic fenestration of the septum pellucidum (septostomy), and lesion biopsy, which led to a histopathological diagnosis. Hemiparesis can accompany unilateral hydrocephalus caused by neurosarcoidosis. Endoscopic procedures provide an effective option for the diagnosis and treatment of noncommunicating hydrocephalus caused by neurosarcoidosis.

Aseptic meningitis with recurrent headache episodes, vomiting, and central fever as first manifestation of isolated neurosarcoidosis: a case report

BACKGROUND

Neurosarcoidosis is a rare entity, usually within the context of systematic sarcoidosis. Isolated neurosarcoidosis and especially a manifestation with pachymeningitis is a notable rarity.

CASE REPORT

A 26-year-old patient presented to the emergency department with acute onset, recurrent episodes of occipital headaches spreading over the whole cranium and vomiting without food consumption, for three days. The clinical examination did not reveal any neurological deficits. The laboratory exams showed no pathological findings. A CT examination with angiography did not detect any acute intracranial or vessel pathology. A lumbar puncture was performed to rule out subarachnoid hemorrhage. The results showed a lymphocytic pleocytosis of 400/µL, elevated protein levels of 1077 mg/dL and reduced glucose levels (CSF: 55 mg/dL, Serum: 118 mg/dL). Extensive infectiological examinations did not reveal any signs of infection, including Borrelia spp. and M. tuberculosis. No positive auto-antibodies or vasculitis-related auto-antibodies were detected. The CSF analysis showed negative oligoclonal bands but an isolated increase in β2-microglobulin, neopterin, and IL-2R levels. The MRI examination revealed a dural gadolinium-enhancement, pronounced in the basal cerebral structures and the upper segment of the cervical spine, consistent with neurosarcoidosis. Corticosteroid treatment rapidly led to a significant improvement of the symptoms. No systemic manifestations of sarcoidosis were found.

CONCLUSIONS

This case report aims to highlight aseptic meningitis with atypical, acute onset headache attacks as a possible manifestation of isolated neurosarcoidosis. Neurosarcoidosis is a clinical entity that requires prompt treatment to avoid permanent neurological deficits.

A Comprehensive Characterization of Patients with Spinal Cord Neurosarcoidosis: A Single Center Cross-Sectional Study of Clinical Outcomes

Background/Objective: To describe the clinical features and radiological outcomes of patients with spinal cord neurosarcoidosis, treatments, and long-term follow-up for this rare disorder. Methods: A cross-sectional, retrospective medical chart review was performed for all patients with spinal cord neurosarcoidosis treated at a single center between 01/1995 and 12/2020. Radiological imaging, laboratory test results, the type of immunosuppressive therapy, and function test scores were reviewed. Results: We assessed 39 patients with spinal cord neurosarcoidosis (23 men, 16 women, mean age at presentation 46.4 years, SD 10.2 years). The mean (SD) duration of spinal cord neurosarcoidosis at data abstraction was 9.8 (6.3) years. There were 24 patients (62%) with extensive intramedullary lesions, 8 (21%) with multiple patchy intramedullary lesions, 12 (31%) with leptomeningeal involvement, and 7 (18%) with nerve root enhancement. The cervical spine was the most commonly affected region in 33 patients (85%). The most common presenting symptoms were paresthesia/neuropathic pain in 20 (51%) and weakness of extremities in 15 (38%) patients. Most patients (n = 37; 95%) had been treated with corticosteroids at symptom onset, and methotrexate was the most used immunosuppressive therapy (n = 19; 49%). Of 34 patients with follow-up magnetic resonance imaging (MRI) available, the median time to improvement per MRI was 10.8 months (95% CI, 6.1-17.0 months). Of 31 patients with MRI enhancement at presentation, 18 (58%) had complete enhancement resolution at follow-up, with a median time to resolution of 51.8 months (95% CI, 24.9-83.4 months). Patients had significantly lower pyramidal (p = 0.004) and sensory functional (p = 0.031) systems scores from presentation to the last clinic visit. Conclusions: Because spinal cord neurosarcoidosis is challenging to diagnose and no set treatment guidelines exist, clarifying patients' clinical parameters and responses to various treatments is needed to improve timely and efficient care. The incidence of spinal cord involvement in sarcoidosis in our cohort was higher than intracranial involvement and most patients had a long extensive intramedullary lesion. We also observed that most patients with spinal cord neurosarcoidosis improved clinically and radiologically after treatment; however, the resolution of MRI enhancement after immunosuppressive therapy may take years. Prospective studies of neurosarcoidosis will be crucial to address questions about effective treatment and long-term prognosis.

Diagnostic value of soluble Interleukin-2 receptor in patients suffering neurosarcoidosis: A systematic review

Background

Neurosarcoidosis is an inflammatory granulomatous disease. Up to 25% of occult sarcoidosis affecting the nervous system are only detected by autopsy. In addition, in recent years the suspicion arose that the soluble Interleukin-2 Receptor (sIL-2R) might be useful in differentiating between neurosarcoidosis and neurosarcoidosis-like diseases such as neurotuberculosis, multiple sclerosis, or cerebral lymphoma.

Objectives

Therefore, we aimed to systematically review randomized controlled trials (RCT), observational studies, and case-control studies evaluating sIL-2R levels in neurosarcoidosis patients.

Design

For this systematic review, a comprehensive literature search of electronic databases including EMBASE, The Web Of Science, The Cochrane Library, MEDLINE, and Google Scholar was conducted. The search was limited to the English language and publication date up to January 08th, 2024.

Data Sources and Methods

As part of the search strategy conducted, 6 articles met the inclusion criteria. Two independent reviewers extracted the relevant data from each article. In addition, 2 independent reviewers assessed the quality of each study using the Newcastle-Ottawa Scale (NOS).

Results

We included 6 studies comprising 98 patients suffering from neurosarcoidosis, 525 non-sarcoidosis patients, and 118 healthy controls. Included studies were published between 2010 and 2023. Cerebrospinal fluid (CSF) sIL-2R levels differed significantly between neurosarcoidosis patients and multiple sclerosis, vasculitis, and healthy controls whereas serum sIL-2R levels did not reveal sufficient discriminative power. sIL-2R index was able to discriminate neurosarcoidosis from neurotuberculosis, bacterial/viral meningitis, and healthy controls.

Conclusions

In this systematic review, we found indications that sIL-2R may be a useful biomarker for the diagnosis of neurosarcoidosis. To determine an additional diagnostic value of sIL-2R, large prospective studies are needed that not only examine absolute sIL-2R levels in serum or CSF but also the dynamic changes as well as the implications of renal function on sIL-2R levels.

An Atypical Presentation of a Patient With Neurosarcoidosis: A Case Report

Neurosarcoidosis is a disease in which noncaseating granulomas, characteristic of sarcoidosis, are found within organs of the nervous system such as the brain and spinal cord. This case report highlights a 57-year-old male with worsening bilateral lower extremity weakness and numbness in addition to ptosis and oculomotor nerve palsy of the right eye. Computed tomography (CT) imaging showed mediastinal and hilar lymphadenopathy, which raised suspicion for neurosarcoidosis. Multiple biopsies were taken from lymph nodes in the mediastinal region, which resulted in non-necrotizing epithelioid cell granulomas, consistent with the suspected neurosarcoidosis. Medical providers must include neurosarcoidosis within a much broader differential diagnosis when encountering patients that present with a similar presentation shown in this case report so that treatment can be promptly initiated as soon as possible.

Neurologic Manifestations of Rheumatologic Disorders

OBJECTIVE

This article provides an overview of the neurologic manifestations of sarcoidosis and select rheumatologic disorders. An approach to the assessment and differential diagnosis of characteristic clinical presentations, including meningitis and vasculitis, is also reviewed. A review of treatment options is included as well as discussion of distinct areas of overlap, including rheumatologic disease in the setting of neuromyelitis spectrum disorder and demyelinating disease in the setting of tumor necrosis factor-α inhibitors.

LATEST DEVELOPMENTS

An increased understanding of the immune mechanisms involved in sarcoidosis and rheumatologic diseases has resulted in a greater diversity of therapeutic options for their treatment. Evidence directing the treatment of the central nervous system (CNS) manifestations of these same diseases is lacking, with a paucity of controlled trials.

ESSENTIAL POINTS

It is important to have a basic knowledge of the common CNS manifestations of rheumatologic diseases and sarcoidosis so that they can be recognized when encountered. In the context of many systemic inflammatory diseases, including systemic lupus erythematosus, IgG4-related disease, and sarcoidosis, CNS disease may be a presenting feature or occur without systemic manifestations of the disease, making familiarity with these diseases even more important.

Neurosarcoidosis manifesting as cavernous sinus syndrome in systemic sarcoidosis

Neurosarcoidosis can manifest in various neurological presentations. The occurrence of cavernous sinus involvement in neurosarcoidosis is rare, which can complicate the diagnostic process. We present a case of neurosarcoidosis demonstrating progressively deteriorating right cavernous sinus syndrome in a woman in her 50s, affecting the oculomotor, abducens and the ophthalmic division of the trigeminal nerves. MRI demonstrated meningeal thickening along the lateral wall of the right cavernous sinus, and a pan-CT scan of the chest, abdomen and pelvis revealed disseminated sarcoidosis involving the lungs and the liver. Histopathological analysis of the liver lesion ultimately confirmed the diagnosis of sarcoidosis. This case underscores the significance of considering neurosarcoidosis as a potential cause of cavernous sinus syndrome. In such cases, early initiation of corticosteroid treatment, with or without steroid-sparing agents, is crucial to prevent disease progression and relapse.

Elsberg Syndrome: A Case Report of a Novel Radiographic Presentation

Introduction: Elsberg syndrome (ES) presents with bowel and bladder dysfunction, resembling cauda equina syndrome, and is classified as a clinicoradiographic syndrome most commonly associated with HSV-2 reactivation. Most cases reveal smooth and continuous nerve enhancement on imaging. Case Description: We present a unique case of ES that presented as several nodular, ring enhancing soft tissue masses along the cauda equina. An 81-year-old woman presented with several weeks of sacral sensory impairment. MRI of the lumbar spine at presentation showed several nodular, ring enhancing soft tissue masses within the thecal sac along the cauda equina, concerning for leptomeningeal carcinomatosis from an unknown primary source. Cerebrospinal fluid (CSF) analysis was notable for lymphocyte predominant pleocytosis and protein elevation, which was nonspecific but suggestive of leptomeningeal carcinomatosis. CSF rapid meningitis panel was positive for HSV2 which was confirmed on HSV2 PCR. The patient was briefly on on acyclovir and was stopped due to lack of meningioencephalitis symptoms. Malignancy workup with cytological analysis and systemic imaging were negative. Given the absence of malignancy and positive HSV2 PCR, the patient was diagnosed with HSV-2 sacral radiculitis and subsequently treated with a full course of intravenous acyclovir with gradual clinical and radiographic improvement. Discussion: Ring-enhancing lesions along the cauda equina are most suggestive of LC. Our case highlights an as of yet unreported presentation of ES which may be valuable for neurologists to be aware of as to avoid any potential diagnostic dilemma, minimize unnecessary and costly testing, and not delay effective treatment.

Longitudinally extensive transverse myelitis as an initial manifestation of sarcoidosis: A rare case and its management

Key Clinical Message

Sarcoidosis-induced LETM represents a rare but life-threatening neurological manifestation of sarcoidosis, characterized by spinal cord inflammation, and associated neurological deficits. Sarcoidosis should be included in the differential diagnosis of LETM, particularly in patients with no lung involvement. Prompt recognition and management are obligatory to optimize outcomes and prevent long-term disability.

Abstract

Sarcoidosis is a multisystem inflammatory granulomatous disorder characterized by the formation of noncaseating granulomas. Although sarcoidosis commonly affects the skin, lymph nodes, and lungs, neurological involvement of sarcoidosis has also been reported. Longitudinally extensive transverse myelitis (LETM) is a rare but well-documented serious manifestation of neuroscoidosis. We report a case of LETM caused by sarcoidosis in a 53-year-old male who presented with progressive bilateral lower extremity weakness, urinary retention, and paresthesia. Laboratory evaluations revealed elevated inflammatory markers. Magnetic resonance imaging of the spine showed hyperintense signals consistent with transverse myelitis. Cerebrospinal fluid analysis revealed lymphocytic pleocytosis and elevated protein levels. Chest computed tomography showed hilar lymphadenopathy. A biopsy of the intrathoracic lymph node showed noncaseating granulomas consistent with sarcoidosis. A diagnosis of sarcoidosis-induced LETM was made after ruling out all other possible etiologies. His condition improved gradually after starting high-dose prednisone, mycophenolate, and rehabilitation strategies. Our case underscores the importance of prompt diagnosis and management of sarcoidosis-induced LETM and highlights that sarcoidosis must be included among differential diagnoses of LETM, especially in cases with no lung involvement.

Blau Syndrome: Challenging Molecular Genetic Diagnostics of Autoinflammatory Disease

The aim of this study was to describe the clinical and molecular genetic findings in seven individuals from three unrelated families with Blau syndrome. A complex ophthalmic and general health examination including diagnostic imaging was performed. The NOD2 mutational hot spot located in exon 4 was Sanger sequenced in all three probands. Two individuals also underwent autoinflammatory disorder gene panel screening, and in one subject, exome sequencing was performed. Blau syndrome presenting as uveitis, skin rush or arthritis was diagnosed in four cases from three families. In two individuals from one family, only camptodactyly was noted, while another member had camptodactyly in combination with non-active uveitis and angioid streaks. One proband developed two attacks of meningoencephalitis attributed to presumed neurosarcoidosis, which is a rare finding in Blau syndrome. The probands from families 1 and 2 carried pathogenic variants in NOD2 (NM_022162.3): c.1001G>A p.(Arg334Gln) and c.1000C>T p.(Arg334Trp), respectively. In family 3, two variants of unknown significance in a heterozygous state were found: c.1412G>T p.(Arg471Leu) in NOD2 and c.928C>T p.(Arg310*) in NLRC4 (NM_001199139.1). In conclusion, Blau syndrome is a phenotypically highly variable, and there is a need to raise awareness about all clinical manifestations, including neurosarcoidosis. Variants of unknown significance pose a significant challenge regarding their contribution to etiopathogenesis of autoinflammatory diseases.

New-Onset Neurosarcoidosis Following Heart Transplant for Cardiac Sarcoidosis

A 63-year-old woman who underwent heart transplantation for cardiac sarcoidosis developed new headache and vision changes. Extensive workup resulted in a diagnosis of neurosarcoidosis treated with pulse dose steroids and infliximab. Recurrence of sarcoidosis after transplantation for isolated cardiac sarcoidosis occurs, but optimal surveillance methods remain unknown.

A Case of Suspected Neurosarcoidosis Evading Diagnosis With Cervical Biopsy

Neurosarcoidosis is a rare manifestation of sarcoidosis, posing diagnostic challenges due to its varied clinical presentation and the lack of definitive diagnostic tests. We present a case of a 46-year-old African American female with progressive ascending bilateral sensory loss, weakness, and a bifrontal headache. Despite undergoing extensive diagnostic workup including cerebrospinal fluid analysis, neuroimaging, and bronchoscopic evaluation, a definitive diagnosis remained elusive. The patient underwent an open cervical spinal cord biopsy, which did not yield conclusive evidence of neurosarcoidosis. Subsequent complications included suspicion of an epidural abscess and post-operative cervical kyphosis. This case underscores the diagnostic dilemma and potential complications associated with the evaluation and management of neurosarcoidosis, highlighting the importance of a multidisciplinary approach in such cases.

Neurosarcoidosis: An under-diagnosed cause of myelopathy

Sarcoidosis is a granulomatous disorder with multi-organ involvement, and etiology still remains unknown. Neurosarcoidosis is the involvement of the nervous system in sarcoidosis. Spinal cord involvement is usually intra-dural, but extra-dural involvement can also occur. Here, we report a case of 30 years old lady presenting with subacute onset paraparesis with bladder and bowel involvement, which was finally diagnosed as sarcoidosis-associated myelopathy with the longitudinally extensive transverse myelitis (LETM) phenotype.

An Unusual Presentation of Neurosarcoidosis in a 64-Year-Old Man: A Case Report

Sarcoidosis is a multisystem granulomatous disorder with an unknown etiology that typically involves the lungs, skin, and lymph nodes, with neurological involvement being relatively rare. We discuss a case of neurosarcoidosis in a 64-year-old man who initially presented with unexplained cognitive impairment, insomnia, hyponatremia, paresthesias, and weight loss and later developed uveitis, diplopia, and dysphagia. Ultimately, findings of hilar and mediastinal lymphadenopathy on chest computed tomography (CT) resulted in bronchoscopy, which led to the diagnosis. This case highlights a rare presentation of sarcoidosis with an unusual constellation of symptoms. We discuss the difficulty involved in diagnosing this disorder as well as its highly variable course.

Challenges in Diagnosis and Therapeutic Strategies in Late-Onset Multiple Sclerosis

Multiple sclerosis (MS) is a chronic inflammatory and degenerative demyelinating disease of the central nervous system of unknown etiology, which affects individuals in their early adulthood. However, nearly 5-10% of people with MS can be diagnosed at ages above 50 years old, referred to as late-onset multiple sclerosis (LOMS). Some studies have reported a distinctive presentation, clinical course, and prognosis for LOMS, implicating a different diagnostic and therapeutic approach for this population. Furthermore, similar manifestations between LOMS and other age-related conditions may lead to potential misdiagnosis and diagnostic delays, and a higher burden of multimorbidity associated with aging can further complicate the clinical picture. This review aims to explore the clinical characteristics, the disease course, and the differential diagnosis of LOMS and addresses therapeutic considerations for this population.

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS): contemporary advances and current controversies

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is an inflammatory syndrome with characteristic clinical, radiological, and pathological features, and can be effectively treated with corticosteroid-based immunotherapies. The exact pathogenesis of CLIPPERS remains unclear, and specific diagnostic biomarkers are not available. According to the 2017 diagnostic criteria, probable CLIPPERS should be considered in middle-aged patients with subacute onset of pontocerebellar symptoms and typical punctuate and curvilinear gadolinium enhancement lesions ("salt-and-pepper" appearance) located in the hindbrain (especially pons) on magnetic resonance imaging. In addition, CLIPPERS-mimics, such as central nervous system (CNS) lymphoma, and several antibody-associated autoimmune CNS diseases (e.g., myelin oligodendrocyte glycoprotein antibody-associated disease, autoimmune glial fibrillary acidic protein astrocytopathy, and anti-N-methyl-D-aspartate receptor encephalitis), should be extensively excluded. The prerequisite for definite CLIPPERS is the perivascular T-cell-predominant inflammatory infiltration observed on pathological analysis. A biopsy is strongly suggested when clinical/radiological red flags are present. Most patients with CLIPPERS respond well to corticosteroids and have a good prognosis. Long-term low-dose corticosteroid maintenance therapy or corticosteroids coupled with immunosuppressants are recommended to prevent the recurrence of the syndrome. The potential progression of CLIPPERS to lymphoma has been suggested in some cases; therefore, at least 2-year clinical and radiological follow-up is essential. Here, we critically review the recent developments and provided an update on the clinical characteristics, diagnostic criteria, differential diagnoses, and therapeutic management of CLIPPERS. We also discuss the current controversies in this context that can be resolved in future research studies.

Cerebral vasculitis as a clinical manifestation of neurosarcoidosis: A scoping review

The occurrence of cerebral vasculitis in individuals with neurosarcoidosis (NS) is considered to be rare. Although the number of relevant publications has increased in recent years, evidence is mostly limited to case reports. To obtain a better understanding of this rare and severe manifestation of disease, we carried out a scoping review on cerebral vasculitis in patients diagnosed with NS. The results of the review indicate that the diagnosis of cerebral vasculitis in patients with NS is made especially in patients with systemic sarcoidosis. However, recurrent strokes in patients with NS remains the main indicator of cerebral vasculitis. A tissue biopsy is considered the gold standard to confirm the diagnosis despite occasional false-negative results. Glucocorticoids and steroid-sparing agents are the most successful current treatments. Favorable outcomes were observed with strategies targeting TNFα and B cells. The goal of this review is to summarize the current literature and treatment options for cerebral vasculitis in patients with NS.

Sarcoid optic neuropathy

A 45-year-old woman presented with sudden complete vision loss in her left eye and retroorbital pain worsened by eye movements. A previous milder episode of vision loss had occurred in the same eye 1 year before, with complete recovery after high-dose intravenous methylprednisolone. She had no light perception in the left eye with a swollen optic disc, but with a normal right optic disc. There were no systemic manifestations or infections. MR scan of the brain showed extensive enlargement and enhancement of the left optic nerve and optic chiasm. After excluding infections and autoimmune markers, a left optic nerve biopsy confirmed non-caseating granulomas, leading to a diagnosis of neurosarcoidosis.

Case report: Psychosis with catatonia in an adult man: a presentation of neurosarcoidosis

Introduction

Sarcoidosis is a multisystem non-caseous granulomatous disease of unknown origin with predominant lung involvement and a variable clinical course. Although rare, neuropsychiatric manifestations such as confusion, problems in orientation, memory dysfunction, delusions, hallucinations and catatonia can be presenting features of sarcoidosis with nervous system involvement, also known as neurosarcoidosis.

Case description

We present a 39-year-old man with acute-onset vertigo, balance problems and confusion quickly developing delusions, hallucinations, catatonic symptoms and suicidal behaviour. Symptoms appeared to be a manifestation of neurosarcoidosis.

Diagnostic assessment

The differential diagnosis of psychosis is broad and should include pertinent auto-immune disorders, paraneoplastic, oncologic, metabolic, and neurodegenerative disorders. Basic systemic screening should include blood and urinary tests, a chest X-ray, brain CT scan and ECG. If neurosarcoidosis is suspected, an MRI of the brain with contrast and lumbar puncture are most appropriate. Multidisciplinary collaboration is essential to arrive at a correct diagnosis and effective management of the patient.

Discussion

Despite the large number of sarcoidosis and psychosis studies, the etiology and pathogenesis of both illnesses remain incompletely understood. A common inflammatory etiopathological pathway has been postulated.

Conclusions

Clinicians should consider organic causes when confronted with a middle-aged patient experiencing a first psychotic episode with an atypical onset, catatonic features, or dysfunction in orientation and/or memory, a complete lack of a positive familial psychiatric history and/or an atypical response to (psycho)pharmacological treatment.

Older Woman With Proptosis, Ptosis, and Blurred Vision

A woman in her early 70s with a history of coronary artery disease, hypertension, and colon polyps presented to oculoplastic surgery with 1 week of progressive right-sided proptosis, headache, right eyelid ptosis, and blurry vision. Outside magnetic resonance imaging demonstrated an infiltrative mass involving right greater than left orbital apices, the right optic nerve, and right extraocular muscles. What would you do next?