Isolated neurosarcoidosis in the medulla oblongata involving the fourth ventricle: a case report

Neurosarcoidosis Mimicking Normal Pressure Hydrocephalus

Two female patients, aged 46 and 51, were referred to the National Hospital for Neurology and Neurosurgery with symptoms resembling normal pressure hydrocephalus (NPH) and with ventriculomegaly on the MRI. Both had a definite diagnosis of neurosarcoidosis (NS) on biopsy, and they underwent the medical and surgical management reserved for NPH. At follow-up, their presenting symptoms had resolved and they had clinically improved. Neurosarcoidosis can mimic NPH, and it should be excluded in patients presenting with NPH.

A rare case of neurosarcoidosis occurred only in the medulla oblongata mimicking malignant brain tumor

Background:

Sarcoidosis is a multisystem disorder characterized by noncaseating epithelioid granulomas. However, neurosarcoidosis occurring only in the medulla oblongata is very rare and lacks specific imaging and clinical features. We report a rare case of neurosarcoidosis arising from the medulla oblongata alone, suggesting the significance of pathological findings for accurate diagnosis.

Case Description:

A 78-year-old woman with a history of rheumatoid arthritis was admitted to our hospital with a 3-month history of progressive numbness in bilateral lower extremities and gait disturbance. Neurological examination on admission showed mild bilateral paired paralysis of the lower limbs (manual muscle test: right 2/V; left 4/V) and marked numbness in the right lower limb. Neuroimaging revealed a solid mass with clear boundaries in the dorsal medulla oblongata appearing hypointense on T1-weighted imaging (WI), hyperintense on T2-WI, and hypointense on diffusion WI (DWI), with strong enhancement on gadolinium-enhanced T1-WI. Cerebrospinal fluid analysis showed moderately elevated levels of protein and lymphocytic cells. Biopsy to determine the exact diagnosis revealed histological findings of noncaseating epithelioid granulomas and inflammatory infiltration, consistent with sarcoidosis. Postoperatively, corticosteroid therapy with prednisolone was initiated as soon as possible, resulting in marked reductions in lesion size. Follow-up neuroimaging after 12 months showed no signs of recurrence.

Conclusion:

Neurosarcoidosis is difficult to diagnose from routine neuroimaging and laboratory findings. Accurate diagnosis requires careful identification of clinical signs, hypointensity on DWI, and morphological findings from surgical biopsy.

Overcoming the Elusiveness of Neurosarcoidosis: Learning from Five Complex Cases

The involvement of the central nervous system in sarcoidosis can manifest with a variety of neurological symptoms, and most of them can be nonspecific. The diagnosis of neurosarcoidosis (NS) can therefore be very challenging without a tissue biopsy. Both computed tomography (CT) and magnetic resonance imaging (MRI) are important imaging modalities in the diagnosis of NS, and MRI is the modality of choice due to its superior soft-tissue contrast resolution. We present a case series of NS with interesting neuroimaging features, complex neurological presentations, and clinical courses. We identify five cases presenting with clinically isolated neurosarcoidosis (CINS) without any other signs or symptoms of systemic disease which were diagnosed as NS on biopsy. In the first case, we describe a patient with an intramedullary cervical spinal cord lesion. In the second case we describe a patient presenting with inflammatory changes and enhancement in the orbit. The third case demonstrates a lesion with calcification around the region of the foramen of Monro. The fourth case shows multiple ring-enhancing lesions. Lastly, the fifth case exhibits unusual findings with both optic neuritis and a cerebellar nodule. We aim to describe the complicated clinical course with neurological workup, neuro-imaging, and eventual diagnosis and treatment of these challenging cases to highlight the variable presentations of NS. This case series will remind clinicians that NS should always be in the differential diagnosis when a patient presents with nonspecific neurological symptoms with unusual neuroimaging findings.

Sarcoidosis of the medulla oblongata causing intractable hiccoughs and numbness of extremities: A case report

RATIONALE

Sarcoidosis is a multisystem disorder characterized by noncaseating granulomas. The nervous system is involved in 5 to 16% of the patients. However, neurosarcoidosis in the medulla oblongata presenting as hiccough is remarkably rare.

PATIENT CONCERN

A 55-year-old female was admitted to our hospital suffering from intractable hiccough and progressive numbness of extremities.

DIAGNOSIS

The MR imaging revealed a circumscribed mass lesion located on the medulla oblongata. The mass was hyperintense on T2-weighted images and enhanced homogeneously with gadolinium-diethylenetriamine penta-acetic acid. The cerebrospinal fluid analysis showed a moderately elevated protein content and a significant lymphocytosis 86.5%. Electrocardiogram (ECG) showed complete atrioventricular block. Bilateral supraclavicular, hilar, and mediastinal lymphadenopathy was diagnosed in a CT scan. Transbranchial needle aspiration biopsy revealed noncaseating granuloma consisting of epithelioid cells, lymphocytes, and rare multinucleated giant cells which was consistent with sarcoidosis. The diagnosis of multisystemic sarcoidosis was made.

INTERVENTIONS AND OUTCOMES

The patient underwent a permanent pacemaker insertion, and was successfully treated with corticosteroids.

LESSONS

It is important to consider neurosarcoidosis in the differential diagnosis of intramedullary lesion, since a right recognition may lead to appropriate treatment with steroids and avoid needlessly extensive surgery.

Case report: middle-aged woman from Ghana with unsteady gait and enlarging cerebellar mass

RATIONALE

Neurosarcoidosis (NS) is an uncommon manifestation of systemic sarcoidosis, with a propensity for middle-agedwomen. Often discovered only at autopsy, rates of neurologic involvement (5%-10%) reported in the literature underscore a lack of sensitivity and specificity in current diagnostic methods.

PATIENT CONCERNS

Herein, we describe a 53-year-old woman who presented with gait imbalance and distal extremity muscular weakness. She was known to harbor a brain mass (4 years in duration) that was monitored and recently seemed to enlarge.

DIAGNOSIS

A subsequent brain biopsy showed necrotizing granulomatous inflammation suggestive of NS. However, no clinical or radiologic evidence of activity was found in other organs.

INTERVENTIONS AND OUTCOMES

Ultimately, endo and transbronchial biopsies were performed, providing histologic confirmation of systemic sarcoidosis.

LESSONS

This approach is advised in all instances of suspected NS where systemic involvement is in question.

Neurosarcoidosis: unusual presentations and considerations for diagnosis and management

BACKGROUND

Sarcoidosis is a chronic, multisystem disease characterised by non-necrotising granulomatous inflammation of unknown aetiology. Most commonly, the lungs, lymph nodes, skin and eyes are affected in sarcoidosis; however, nervous system involvement occurs in approximately 5%-15% of cases. Any part of the nervous system can be affected by sarcoidosis.

CASES

Herein we describe three unusual patient presentations of neurosarcoidosis, one with optic neuritis, a second with hydrocephalus and a third with cervical myelopathy.

CONCLUSIONS

We include pertinent details about their presentations, imaging findings, pathology, management and clinical course.

Neurosarcoidosis as an MS Mimic: The trials and tribulations of making a diagnosis

The clinical presentation of neurosarcoidosis is varied as multiple levels of the neuraxis may be affected. When central nervous system involvement occurs, making an accurate diagnosis of the condition can be challenging, especially given the current definition for definite neurosarcoidosis requires histologic confirmation of the affected tissue (brain biopsy). This article will review our current knowledge and manifestations of neurosarcoidosis, discuss the current diagnostic approach as well as the challenges associated with a condition requiring histologic confirmation, discuss the current treatment approach, and highlight the challenges of this diagnosis with a few real-life clinical cases. We also highlight the selected differential diagnosis of neurosarcoidosis as well as multiple sclerosis which could mimic each other.