Cervical epidural neurosarcoidosis: A case report and literature review

Rare case of multifocal extradural and intramedullary neurosarcoidosis without pulmonary involvement: a case report and literature review

Introduction

Sarcoidosis is a multisystem disease characterized histologically by noncaseating granulomas. Localization of sarcoidosis to the CNS is termed neurosarcoidosis, a complex and rare neuroinflammatory form of sarcoidosis. When the spinal cord is involved, lesions are often intradural. Here, we present a rare case of progressive myelopathy secondary to multifocal spinal extradural neurosarcoidosis with spinal cord compression and without pulmonary involvement.

Case presentation

A 29-year-old African American female presented to the emergency department with numbness and paresthesia of 2-month duration in her left lower extremity and 2-week duration in her right lower extremity. The patient reported difficulty ambulating, paresthesia below the umbilicus, and back pain radiating to bilateral lower extremities. She endorsed 9-month history of cough, subjective fevers, night sweats, and unintentional 15 kg weight loss. Examination revealed 4/5 strength in the left lower extremity. MRI of the brain and spinal cord revealed enhancing extradural lesions, with spinal cord compression at T8 measuring 1.3 × 1.9 cm. Lumbar puncture demonstrated oligoclonal bands and increased CSF neutrophils, lymphocytes, monocytes, and protein. T8 laminectomy with resection of the epidural lesion was performed. Histology showed granulomas, consistent with neurosarcoidosis. At follow-up, repeat spinal MRI revealed disease progression with intramedullary involvement. Long-term immunosuppressive treatment was eventually initiated with satisfactory response.

Discussion

This is a rare case of myelopathy secondary to spinal extradural neurosarcoidosis. Spinal neurosarcoidosis is predominantly an intradural process. Our review of the literature identified only seven cases of extradural neurosarcoidosis presenting with compressive myelopathy. Additional insight into management and rehabilitation following pathological diagnosis is of clinical significance.

Recurrence of Epidural Spinal Sarcoidosis

Neurosarcoidosis involving the spine is uncommon. Sarcoidosis of the spine usually presents as an intramedullary lesion and rarely an epidural lesion. To have recurrence of neurosarcoidosis is an even rarer presentation. Here, we present a 37-year-old man with poorly controlled sarcoidosis who initially presented to our medical center in 2015 with thoracic myelopathy from epidural spinal sarcoidosis treated with thoracic decompression and fusion. He presented to the hospital 5 years later with a month history of progressive upper extremity weakness. MRI revealed recurrent stenosis and spinal cord compression in the cervicothoracic junction. Urgent surgical intervention along with medical management resulted in symptomatic and functional improvement. Surgical intervention and compliance with postoperative corticosteroid therapy seem to yield a favorable prognosis for patients with epidural spinal sarcoidosis and to avoid recurrence.