Truncal polyradiculopathy due to sarcoidosis

Neurosarcoidosis

Sarcoidosis affects the nervous system in 5% of cases. 60% of cases involve the cranial and peripheral nerves, the remainder the central nervous system, in which a leptomeningitis, a pachymeningitis and a vasculitis may arise. Stroke and cerebral haemorrhage may occur, and certain infections in the brain are more likely with sarcoidosis. Patients respond well to treatment but oftentimes with residual neurological impairments which may be severe. A greater understanding of the disease and the need for early treatment and use of biological therapies have improved treatment outcome in recent times.

Bilateral Facial Palsy as the Onset of Neurosarcoidosis: A Case Report and a Revision of Literature

Unilateral facial nerve palsy (FNP) is one of the most common cranial mononeuropathies. Among rare etiologies, neurosarcoidosis (NS) can cause bilateral involvement (both recurring and simultaneous) only in 15% to 25% of cases. The rarity of this systemic disease and its clinical heterogeneity, due to granulomatous inflammation that may affect many anatomic substrates, frequently make the diagnosis a real challenge for the clinician. Based on laboratory and instrumental tests, a careful diagnostic algorithm must be adopted to avoid misdiagnosis and delay in treatment. We present a 52-year-old woman with an acute onset of unilateral right FNP, rapidly developing contralateral involvement (simultaneous bilateral FNP). Lung findings pointed towards a systemic disease, and then lymph node biopsy confirmed NS. Corticosteroid therapy was started. After three years of follow-up, the patient is still in remission with a low prednisone dose. We discuss the differential diagnosis of bilateral FNP, focusing on clinical presentation, diagnosis, and treatment of NS. We have performed a literature revision, confirming bilateral FNP, outside Heerfordt syndrome, to be rare and sometimes represent the only neurological manifestation of NS onset.

Neurosarcoidosis: clinical manifestations, investigation and treatment

Sarcoidosis affects the nervous system in 10% of cases. When it does so it can affect any part of the nervous system and with all degrees of severity. It forms part of the differential diagnosis in inflammatory, infective, neoplastic and degenerative neurological diseases and may be very difficult to diagnose without histological confirmation. Recent clinical studies and the increasing availability of new biological treatments allow a much clearer understanding of the disease. This review summarises its clinical features, imaging and laboratory characteristics, treatment and outcome.

Neurosarcoidosis resulting in thoracic radiculopathy: a case report

Background

Thoracic radiculopathy is a rare etiology of vague abdominal pain. There are few reports of neurosarcoidosis manifesting as a thoracic radiculopathy, which highlights the diagnostic challenge.

Case presentation

A 54-year-old Caucasian man was being investigated for right upper quadrant abdominal pain and was found to have diffuse lymphadenopathy on imaging. He was eventually diagnosed with sarcoidosis. Over time, his abdominal pain progressed to neuropathic pain along his T7–T11 dermatome. Magnetic resonance imaging revealed findings consistent with a thoracic radiculopathy due to neurosarcoidosis. The patient received corticosteroids for treatment of neurosarcoidosis and immunosuppressant therapy to manage neuropathic pain.

Conclusions

This case report highlights the importance of considering thoracic radiculopathies in the differential diagnosis of vague abdominal pain and explores guidelines in diagnosing neurosarcoidosis in the absence of neural tissue biopsy.

Sarcoidosis of the central nervous system: clinical features, imaging, and CSF results

OBJECTIVE

Neurological complications of systemic sarcoidosis are uncommon and the natural history and optimal treatments under-researched. With the advent of modern biological therapies, it is important to define the clinical characteristics and immunopathology of the disease.

METHODS

Patients referred to and treated within the Centre for Neurosarcoidosis over a 15 year period who had biopsy-proven "highly probable" disease of the central nervous system were studied prospectively.

RESULTS

166 patients were studied, of whom two-thirds had involvement of the brain and spinal cord and the remainder cranial neuropathies and radiculopathy. Imaging was abnormal in all those with meningeal and parenchymal diseases, and was normal in 37% of those with cranial neuropathy. Those with leptomeningeal disease had a more severe disorder, with hydrocephalus and tissue destruction, whereas those with pachymeningeal disease had more striking imaging features but less neurological impairment. The CSF was active in 70% of cases, even when imaging was normal. Disability correlated with CSF indices in those with a leptomeningitis. Oligoclonal bands were seen in 30% of cases and correlated with disability and the presence of hydrocephalus. Unmatched bands were seen only in isolated neurological disease.

CONCLUSIONS

This prospective study of neurosarcoidosis increases our understanding of the pathophysiology of the disease. A reclassification of the clinical and imaging features of the disease allows an understanding of its pathophysiology and correlation with CSF indices allows an early identification of those with a more destructive disease will help to define treatment and may thereby improve outcome.

[Neurosarcoidosis presenting with severe hyposmia and polyradiculopathy]

A 50-year-old woman presented with constriction sensation in the lower part of the chest, paresthesia in the right forearm and hypesthesia in the right thigh. One month later, she noticed a loss of sense of smell. The normal findings of the nasal mucosa and the impaired results of standard olfactory acuity test (T&T olfactometry) and intravenous olfactory test (Alinamin test) suggested a lesion proximal to the nasal mucosa. Sensory disturbances in the segmental areas of cervical, thoracic and lumbar regions were clinically and electrophysiologically attributed to polyradiculopathy. MRI of the brain and whole spine revealed no abnormalities. Cerebrospinal fluid examination showed lymphocytic pleocytosis. Sarcoidosis was diagnosed based on the findings including an elevated serum angiotensin-converting enzyme level, bilateral hilar lymphadenopathy on the chest CT and histological evidence of noncaseating granulomas. Methylprednisolone pulse therapy improved the olfactory and sensory disturbances. Neurosarcoidosis should be considered in the differential diagnosis of olfactory impairment.