Spinal leptomeningeal sarcoidosis

Idiopathic Hypertrophic Spinal Pachymeningitis with Spinal Cord Lesion: A Case Report

Idiopathic hypertrophic spinal pachymeningitis (IHSP) is a rare, diffuse inflammatory fibrosis of the dura mater that can lead to spinal cord compression. Though the optimal treatment is controversial, some reports recommend decompressive surgery and postoperative steroid therapy. However, we encountered a case of pachymeningitis that worsened after decompressive surgery. A 79-year-old woman presented with gait disturbance and bilateral lower extremity weakness that began 6 months prior. She had radiating pain on the C5 and T1 dermatomes and clumsiness in both hands. Magnetic resonance imaging (MRI) revealed diffuse thickening of the posterior longitudinal ligament of C6 to T4/5 and ligamentum flavum of C3/4 to T4/5, causing central canal stenosis and compressive myelopathy. She underwent posterior decompressive laminectomy from C4 to T1 total (T2 subtotal) and cervicothoracic screw fixation. During surgery, we found severe adhesion of the posterior longitudinal ligament and ligamentum flavum to the dura mater. Chronic inflammation with fibrosis and lymphoplasmacytic infiltration were present. After surgery, the patient's motor weakness worsened. Despite steroid treatment, her symptom severity fluctuated. Follow-up MRI obtained 3 months postoperation revealed high signal intensity from C5 to T2, possibly indicating aggravated compressive myelopathy. Thus, in this case, decompressive surgery and steroid therapy were detrimental.

Idiopathic hypertrophic spinal pachymeningitis

Spinal idiopathic hypertrophic pachymeningitis (IHP) is a rare, chronic, nonspecific, granulomatous inflammatory disorder of the dura with unknown etiology. It can cause a localized or diffuse thickening of the dura mater with compression of the spinal canal and possible myelopathic symptoms. The authors report 3 consecutive cases of spinal IHP with a review of the literature. The diagnosis of spinal IHP was based on biopsy and pathological confirmation. Typical MR imaging findings suggestive of spinal IHP were noted in all cases. The clinical course may be marked by deterioration despite conservative therapy and may require surgical intervention to prevent irreversible neurological damage. Therefore, prompt diagnosis and institution of proper treatment is critical.

Idiopathic hypertrophic spinal pachymeningitis: a case report

A 67-year-old man presented with progressive quadriplegia. Magnetic resonance imaging (MRI) revealed spinal cord compression by a thickened dura ventral to the cord from C3 to C7. The lesion was isointense on both T1- and T2-weighted images, and showed contrast enhancement on T1-weighted gadorinium-enhanced images. A diagnosis of idiopathic hypertrophic spinal pachymeningitis was confirmed histologically after anterior decompression and fusion. Only partial excision was achieved. Marked improvement of the quadriplegia was attained only after steroid therapy. At the 3-month follow-up, the patient was able to walk with a cane. The affected site showed no remission on MRI despite continuous steroid therapy. At the 2-year follow-up, the patient could walk independently.

Hypertrophic spinal pachymeningitis associated with heavy-chain disease. Case report

The authors present a case of concurrent hypertrophic spinal pachymeningitis (HSP) and heavy-chain disease (HCD). The patient was a 71-year-old woman presenting with leg paralysis and fever. Laminectomy was performed for thoracic HSP, and chemotherapy was administered for HCD. Because the dura mater was not surgically opened, marked hypertrophy remained postoperatively. Once the HCD was controlled by chemotherapy, the fever subsided and the hypertrophy was resolved. No previous reports have supported a link between the two diseases. Idiopathic HSP may be secondary to rare conditions such as HCD, and systemic examinations should be performed to the fullest extent possible to investigate the possibility of some underlying disease.

Idiopathic hypertrophic pachymeningitis: a report of two patients and review of the literature

PURPOSE

We report the treatment and follow-up, including MRI, of two patients with idiopathic hypertrophic pachymeningitis and review the English language literature, with emphasis on management and outcome in this rare disorder.

METHODS AND MATERIALS

The files of two patients were reviewed, with relevant histopathology and imaging (MRI). The first patient has been followed for sixteen years (the longest MRI-documented postoperative course reported for this condition) and the second for two years. The English language literature was reviewed, including a summary of all reported patients that have been followed with MRI or CT imaging.

RESULTS

Despite extensive investigation, no underlying etiology was determined in either patient. Histopathological studies revealed a chronic inflammatory dural infiltrate in both patients, with granulomas in the first but not the second patient. The first patient underwent surgery twice and has remained stable for sixteen years, despite persistent neurologic deficits. The second patient was managed with dexamethasone after a surgical biopsy, and experienced complete resolution of all neurological deficits and abnormalities seen with MRI.

CONCLUSIONS

Although prompt and extensive surgery has been recommended for this condition, the results from our second patient indicate that complete remission can be achieved in some patients with biopsy and steroid therapy. This also supports the view that autoimmune mechanisms underlie idiopathic hypertrophic pachymeningitis. The first patient illustrates that extensive laminectomies may be an effective therapeutic option but chronic discomfort may result. If extensive surgery must be performed, laminoplasty should be done because of the potential for reduced pain and improved long-term spinal stability.

Idiopathic hypertrophic cranial pachymeningitis with perifocal brain edema--case report

A 51-year-old female presented with an extremely rare case of idiopathic hypertrophic cranial pachymeningitis manifesting as markedly thickened frontotemporal meninges with expanding perifocal edema. Magnetic resonance imaging with gadolinium revealed enhancement of the thickened dura mater protruding into the brain parenchyma accompanied by focal edema causing a mass effect. Histological examination of a biopsy specimen revealed thickened dura with infiltrating lymphocytes. Serological and immunological tests were normal. No inflammatory response or evidence of malignant tumors was observed. The patient was treated with predonisolone, resulting in marked improvement of the mass effect. High-dose steroid therapy appears to be effective for intracranial pachymeningitis associated with expanding perifocal brain edema.

"Idiopathic" cranial hypertrophic pachymeningitis responsive to antituberculous therapy: case report

OBJECTIVE AND IMPORTANCE

We present a case similar to previously described cases of idiopathic hypertrophic cranial pachymeningitis. However, our patient responded to antituberculous therapy. This raises the possibility that some cases of "idiopathic" hypertrophic cranial pachymeningitis may represent occult tuberculous disease.

CLINICAL PRESENTATION

A 55-year-old woman presented with a right fourth nerve palsy and a 5-month history of headaches. Magnetic resonance imaging with gadolinium revealed thick enhancing dura on the right half of the tentorium cerebelli, with edema of the adjacent midbrain, pons, and cerebral peduncle.

INTERVENTION

Open biopsy of the tentorial lesion revealed only dense fibrosis with histiocytic infiltration. An exhaustive search failed to demonstrate an underlying cause. In particular, mycobacterial stains/cultures were negative, there was no granuloma formation, and the chest x-ray was unremarkable. However, because of a strongly positive purified protein-derivative skin test and residence in an area endemic for tuberculosis, the patient was placed on antituberculous medications.

CONCLUSION

The patient's symptoms and signs resolved with antituberculous therapy. Resolution of the tentorial lesion was confirmed by gadolinium-enhanced magnetic resonance imaging. We conclude that this case represented occult tuberculous disease. An empiric trial of antituberculous therapy may be warranted in other cases of apparently idiopathic hypertrophic cranial pachymeningitis.

Solitary spinal cord sarcoidosis without other manifestations of systemic sarcoidosis

We report a biopsy-proven case of sarcoidosis limited to the spinal cord and responsive to treatment with oral corticosteroids. Involvement of the spinal cord by systemic sarcoidosis is uncommon and is associated with several unusual pathological and radiological characteristics that may contribute to its misdiagnosis and subsequent mismanagement. The importance of these unusual characteristics is greatly amplified in solitary spinal cord sarcoidosis because there are no systemic findings to suggest a sarcoid etiology.

Neurosarcoidosis of the conus medullaris and cauda equina presenting as paraparesis: case report and literature review

Sarcoidosis is a multi-system, non-caseating granulomatous disease of unknown etiology. Although spinal cord involvement is rare, it may cause severe neurological complications. We report the case of a 52-year-old woman who developed low back pain and a progressive flaccid paraparesis whose investigations revealed pulmonary and spinal sarcoidosis. To our knowledge, this is the first reported case of sarcoidosis of the conus medullaris and cauda equina diagnosed by an unusual enhancement pattern observed on magnetic resonance imaging with gadolinium. Biopsy of the lumbar nerve roots and of the lung revealed a non-caseating granuloma. Treatment with steroids and intensive rehabilitation resulted in remarkable functional improvement. Although rare, sarcoidosis of the conus medullaris and cauda equina should be considered in the differential diagnosis of flaccid paraparesis, particularly in patients with non-diagnostic evaluations.