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Rodrigues RA, Alves T, Sousa JA, Jorge A, Geraldo A. Longitudinally Extensive Transverse Myelitis as a First Manifestation of Sarcoidosis. Cureus 2023; 15:e44037. [PMID: 37746508 PMCID: PMC10517641 DOI: 10.7759/cureus.44037] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 09/26/2023] Open
Abstract
Longitudinally extensive transverse myelitis (LETM) is a debilitating inflammatory spinal cord lesion involving several spinal segments. There are several possible etiologies, with spinal cord sarcoidosis being a rare cause of LETM. Spinal cord sarcoidosis is, in itself, a rare manifestation of sarcoidosis that can be difficult to diagnose, especially in patients with no prior history of systemic sarcoidosis, frequently leading to a delayed diagnosis. We report the case of a 53-year-old man who developed LETM as the first manifestation of sarcoidosis. The patient presented with progressive lower limb weakness, urinary retention, sensory disturbances, and muscle spasms. Imaging studies showed hyperintense lesions extending over multiple spinal segments. After the exclusion of other causes and a lymph node biopsy showing non-caseating granulomas, the diagnosis of LETM secondary to sarcoidosis was confirmed.
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Affiliation(s)
| | - Telma Alves
- Internal Medicine, University Hospital Center of Coimbra, Coimbra, PRT
| | - João A Sousa
- Neurology, University Hospital Center of Coimbra, Coimbra, PRT
| | - Andre Jorge
- Neurology, University Hospital Center of Coimbra, Coimbra, PRT
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Уханова ЮА, Иловайская ИА, Терпигорев СА. [Panhypopituitarism as the first manifestation of sarcoidosis: case report]. PROBLEMY ENDOKRINOLOGII 2022; 68:46-51. [PMID: 36104964 PMCID: PMC9762432 DOI: 10.14341/probl13115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/27/2022] [Accepted: 06/15/2022] [Indexed: 01/09/2023]
Abstract
Sarcoidosis is a systemic inflammatory disease of unknown etiology characterized by the formation of noncaseating granulomas in various organs and tissues and the activation of T-cells at the site of granulomatous inflammation with the release of various chemokines and cytokines [1]. The incidence on average ranges from 10 to 20 per 100,000 population [2]. Most often in patients with sarcoidosis, lesions of the lungs and intrathoracic lymph nodes are detected. Significantly less often (in about 5-20% of patients) damage to the nervous system is noted [6,7,9]. In 9-18% of patients with neurosarcoidosis, involvement of the pituitary gland, pituitary infundibulum and hypothalamus is found, which is manifested by a variety of clinical symptoms [8,10]. We observed a patient with sarcoidosis whose disease debuted with clinical symptoms of hypogonadism, followed by the development of signs of secondary hypothyroidism, adrenal insufficiency, and diabetes insipidus, which was initially regarded as panhypopituitarism against the background of a hypothalamic lesion of unknown origin. Later, additional examination revealed signs of intrathoracic lymphadenopathy and focal changes in the lung parenchyma on CT, as well as skin lesions. Despite the biochemical compensation of hypopituitarism, the clinical efficacy of hormonal therapy with cabergoline, testosterone, hydrocortisone and levothyroxine sodium was insufficient, and the patient's condition improved after the addition of immunosuppressive and anti-inflammatory therapy with methotrexate and methylprednisolone.
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Affiliation(s)
- Ю. А. Уханова
- Московский областной научно-исследовательский клинический институт им. М.Ф. Владимирского
| | - И. А. Иловайская
- Московский областной научно-исследовательский клинический институт им. М.Ф. Владимирского
| | - С. А. Терпигорев
- Московский областной научно-исследовательский клинический институт им. М.Ф. Владимирского
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How to Tackle the Diagnosis and Treatment in the Diverse Scenarios of Extrapulmonary Sarcoidosis. Adv Ther 2021; 38:4605-4627. [PMID: 34296400 PMCID: PMC8408061 DOI: 10.1007/s12325-021-01832-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/17/2021] [Indexed: 11/19/2022]
Abstract
Extrapulmonary sarcoidosis occurs in 30–50% of cases of sarcoidosis, most often in association with pulmonary involvement, and virtually any organ can be involved. Its incidence depends according to the organs considered, clinical phenotype, and history of sarcoidosis, but also on epidemiological factors like age, sex, geographic ancestry, and socio-professional factors. The presentation, symptomatology, organ dysfunction, severity, and lethal risk vary from and to patient even at the level of the same organ. The presentation may be specific or not, and its occurrence is at variable times in the history of sarcoidosis from initial to delayed. There are schematically two types of presentation, one when pulmonary sarcoidosis is first discovered, the problem is then to detect extrapulmonary localizations and to assess their link with sarcoidosis, while the other presentation is when extrapulmonary manifestations are indicative of the disease with the need to promptly make the diagnosis of sarcoidosis. To improve diagnosis accuracy, extrapulmonary manifestations need to be known and a medical strategy is warranted to avoid both under- and over-diagnosis. An accurate estimation of impairment and risk linked to extrapulmonary sarcoidosis is essential to offer the best treatment. Most frequent extrapulmonary localizations are skin lesions, arthritis, uveitis, peripheral lymphadenopathy, and hepatic involvement. Potentially severe involvement may stem from the heart, nervous system, kidney, eye and larynx. There is a lack of randomized trials to support recommendations which are often derived from what is known for lung sarcoidosis and from the natural history of the disease at the level of the respective organ. The treatment needs to be holistic and personalized, taking into account not only extrapulmonary localizations but also lung involvement, parasarcoidosis syndrome if any, symptoms, quality of life, medical history, drugs contra-indications, and potential adverse events and patient preferences. The treatment is based on the use of anti-sarcoidosis drugs, on treatments related to organ dysfunction and supportive treatments. Multidisciplinary discussions and referral to sarcoidosis centers of excellence may be helpful for difficult diagnosis and treatment decisions.
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Sève P, Pacheco Y, Durupt F, Jamilloux Y, Gerfaud-Valentin M, Isaac S, Boussel L, Calender A, Androdias G, Valeyre D, El Jammal T. Sarcoidosis: A Clinical Overview from Symptoms to Diagnosis. Cells 2021; 10:cells10040766. [PMID: 33807303 PMCID: PMC8066110 DOI: 10.3390/cells10040766] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 12/11/2022] Open
Abstract
Sarcoidosis is a multi-system disease of unknown etiology characterized by the formation of granulomas in various organs. It affects people of all ethnic backgrounds and occurs at any time of life but is more frequent in African Americans and Scandinavians and in adults between 30 and 50 years of age. Sarcoidosis can affect any organ with a frequency varying according to ethnicity, sex and age. Intrathoracic involvement occurs in 90% of patients with symmetrical bilateral hilar adenopathy and/or diffuse lung micronodules, mainly along the lymphatic structures which are the most affected system. Among extrapulmonary manifestations, skin lesions, uveitis, liver or splenic involvement, peripheral and abdominal lymphadenopathy and peripheral arthritis are the most frequent with a prevalence of 25-50%. Finally, cardiac and neurological manifestations which can be the initial manifestation of sarcoidosis, as can be bilateral parotitis, nasosinusal or laryngeal signs, hypercalcemia and renal dysfunction, affect less than 10% of patients. The diagnosis is not standardized but is based on three major criteria: a compatible clinical and/or radiological presentation, the histological evidence of non-necrotizing granulomatous inflammation in one or more tissues and the exclusion of alternative causes of granulomatous disease. Certain clinical features are considered to be highly specific of the disease (e.g., Löfgren's syndrome, lupus pernio, Heerfordt's syndrome) and do not require histological confirmation. New diagnostic guidelines were recently published. Specific clinical criteria have been developed for the diagnosis of cardiac, neurological and ocular sarcoidosis. This article focuses on the clinical presentation and the common differentials that need to be considered when appropriate.
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Affiliation(s)
- Pascal Sève
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
- Université Claude Bernard Lyon 1, Research on Healthcare Performance (RESHAPE), INSERM U1290, 69007 Lyon, France
- Correspondence:
| | - Yves Pacheco
- Faculty of Medicine, University Claude Bernard Lyon 1, F-69007 Lyon, France;
| | - François Durupt
- Department of Dermatology, Lyon University Hospital, 69004 Lyon, France;
| | - Yvan Jamilloux
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
| | - Mathieu Gerfaud-Valentin
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
| | - Sylvie Isaac
- Department of Pathology, Lyon University Hospital, 69310 Pierre Bénite, France;
| | - Loïc Boussel
- Department of Radiology, Lyon University Hospital, 69004 Lyon, France
| | - Alain Calender
- Department of Genetics, Lyon University Hospital, 69500 Bron, France;
| | - Géraldine Androdias
- Department of Neurology, Service Sclérose en Plaques, Pathologies de la Myéline et Neuro-Inflammation, Hôpital Neurologique Pierre Wertheimer, Lyon University Hospital, F-69677 Bron, France;
| | - Dominique Valeyre
- Department of Pneumology, Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne et Université Paris 13, Sorbonne Paris Cité, 93008 Bobigny, France;
| | - Thomas El Jammal
- Department of Internal Medicine, Lyon University Hospital, 69007 Lyon, France; (Y.J.); (M.G.-V.); (T.E.J.)
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Nordström S, Andersson B, Malmeström C. Cerebrospinal fluid CD4 + /CD8 + ratio in diagnosing neurosarcoidosis. Acta Neurol Scand 2020; 142:480-485. [PMID: 32533774 DOI: 10.1111/ane.13297] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/13/2020] [Accepted: 06/06/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Neurosarcoidosis affects 5%-10% of patients with sarcoidosis. CD4+ /CD8+ ratio in bronchoalveolar lavage is included in diagnostic routine for pulmonary sarcoidosis. Previously, it has been suggested that a cerebrospinal fluid CD4+ /CD8+ ratio ≥5 can be an aid in diagnosing neurosarcoidosis. MATERIALS AND METHODS This study included 66 cases where neurosarcoidosis was a differential diagnosis and hence subjected to the analysis of CSF CD4+ /CD8+ ratio by flow cytometry. RESULTS Eleven cases of neurosarcoidosis, had a significantly higher median CSF CD4+ /CD8+ ratio than the other group, P = .024. The median CSF CD4+ /CD8+ ratio was 4.2, hence not reaching the suggested level of ≥5 for diagnosing neurosarcoidosis. When combined, the elevated CSF CD4+ /CD8+ ratio ≥5 and an elevated CSF lymphocyte count (>3 lymphocytes/uL) gave a positive predictive value of 57% and a high negative predictive value of 88%, with a specificity of 95% for neurosarcoidosis. CONCLUSION The study confirms that increased CSF CD4+ /CD8+ ratio is associated with neurosarcoidosis but cannot alone distinguish the conditions from other neurological diagnoses. However, a ratio below <5 combined with an absence of pleocytosis in CSF yields a negative predictive value (NPV) of 88% suggesting a role for the analysis in differential diagnosing neuroinflammatory conditions.
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Affiliation(s)
- Sara Nordström
- Department of Neurology University of Gothenburg Gothenburg Sweden
- Institute of neuroscience and physiology University of Gothenburg Gothenburg Sweden
| | - Bengt Andersson
- Laboratory for Clinical Immunology University of Gothenburg Gothenburg Sweden
- Sahlgrenska university hospital University of Gothenburg Gothenburg Sweden
| | - Clas Malmeström
- Department of Neurology University of Gothenburg Gothenburg Sweden
- Institute of neuroscience and physiology University of Gothenburg Gothenburg Sweden
- Laboratory for Clinical Immunology University of Gothenburg Gothenburg Sweden
- Sahlgrenska university hospital University of Gothenburg Gothenburg Sweden
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Abstract
Hypothalamo-pituitary sarcoidosis is a rare manifestation of sarcoidosis, usually presenting alongside other symptoms of neurosarcoidosis. We describe the case of a 58-year-old man from Ghana who presented with progressive gait disturbance, cognitive dysfunction, hypothermia and bradycardia. He was found to have pituitary stalk thickening on imaging, and lymph node biopsy identified non-caseating granulomatous disease. Serology revealed gonadotropin deficiency, hypothyroidism and central adrenal insufficiency. Treatment with immunomodulatory therapy resulted in resolution of findings on imaging and improved cognition, though pituitary function never recovered. Treatment for his sarcoidosis unfortunately resulted in recurrent infections and avascular necrosis. Work-up, management and ongoing care required multidisciplinary cooperation between the admitting internal medicine team, infectious diseases, respirology, rheumatology, endocrinology and neurology.
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Affiliation(s)
- Elina Liu
- Department of Internal Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Axel Rohr
- Department of Neuroradiology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohammed AlMehthel
- Department of Endocrinology, The University of British Columbia, Vancouver, British Columbia, Canada
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Kent L, Hofer M, Arun T. Hydrocephalus as a presenting manifestation in neurological sarcoidosis: Recognition and challenges in management. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Arun T, Pattison L, Palace J. Distinguishing neurosarcoidosis from multiple sclerosis based on CSF analysis: A retrospective study. Neurology 2020; 94:e2545-e2554. [PMID: 32354749 DOI: 10.1212/wnl.0000000000009491] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 12/04/2019] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To characterize a cohort of patients with neurosarcoidosis with particular focus on CSF analysis and to investigate whether CSF values could help in distinguishing it from multiple sclerosis (MS). METHODS This retrospective cohort study enrolled 85 patients with a diagnosis of neurosarcoidosis (possible, probable, or definite). CSF total protein, white cell count, and angiotensin-converting enzyme levels were measured. CSF and serum oligoclonal immunoglobulin G (IgG) patterns were analyzed with the use of odds ratios and binary logistic regression. RESULTS Eighty patients had a probable (nonneural positive histology) or definite (neural positive histology) diagnosis of neurosarcoidosis. Most frequent findings on MRI were leptomeningeal enhancement (35%) and white matter and spinal cord involvement (30% and 23%). PET scan showed avid areas in 74% of cases. CSF analysis frequently showed lymphocytosis (63%) and elevated protein (62%), but CSF-selective oligoclonal bands were rare (3%). Serum ACE levels were elevated in 51% of patients but in only 14% of those with isolated neurosarcoidosis. Elevated CSF ACE was not found in any patient. CONCLUSIONS Large elevations in total protein, white cell count, and serum ACE occur in neurosarcoidosis but are rare in MS. The diagnostic use of these tests is, however, limited because minimal changes may occur in both. MS clinical mimics in neurosarcoidosis are not common, and intrathecal synthesis of oligoclonal IgG is a powerful discriminator because it is rare in neurosarcoidosis but occurs in 95% to 98% cases of MS. We suggest caution in making a diagnosis of neurosarcoidosis when intrathecal oligoclonal IgG synthesis is found.
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Affiliation(s)
- Tarunya Arun
- From the University Hospitals of Coventry and Warwickshire (T.A., L.P.); and Oxford University Hospitals (J.P.), Oxford, UK.
| | - Laura Pattison
- From the University Hospitals of Coventry and Warwickshire (T.A., L.P.); and Oxford University Hospitals (J.P.), Oxford, UK
| | - Jacqueline Palace
- From the University Hospitals of Coventry and Warwickshire (T.A., L.P.); and Oxford University Hospitals (J.P.), Oxford, UK
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Abstract
Peripheral neuropathies are probably an under-diagnosed complication of many rheumatic diseases. In some cases they take a mild clinical course, in others they cause severe impairment of patients' quality of life. A precise diagnosis and etiological classification are of major importance for successful treatment and prognosis of peripheral neuropathies. A detailed patient history and physical examination are the foundation of every diagnostic approach. Electrophysiological studies are obligatory when peripheral neuropathy is suspected, whereas nerve or nerve-muscle biopsies are indicated only in selected cases. Therapeutic approaches are often complicated by a lack of evidence. They correspond to frequently tested immunosuppressive treatment of the underlying disease, such as glucocorticoids, cyclophosphamide, mycophenolate mofetil and intravenous immunoglobulins and are based on the symptomatic pain treatment of other neuropathies. As first-line treatment gabapentin, pregabalin, duloxetine, venlafaxine and tricyclic antidepressants are frequently used.
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Boban J, Thurnher MM. Ventral-subpial enhancement in spinal cord sarcoidosis: A braid-like sign. Neurology 2019; 92:236-238. [PMID: 30593521 DOI: 10.1212/wnl.0000000000006857] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 10/11/2018] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jasmina Boban
- From the Department for Biomedical Imaging and Image-guided Therapy, Section of Neuroradiology and Musculoskeletal Radiology, University Hospital Vienna, Austria. Dr. Boban's permanent affiliation is Department of Radiology, Faculty of Medicine, University of Novi Sad, Serbia
| | - Majda M Thurnher
- From the Department for Biomedical Imaging and Image-guided Therapy, Section of Neuroradiology and Musculoskeletal Radiology, University Hospital Vienna, Austria. Dr. Boban's permanent affiliation is Department of Radiology, Faculty of Medicine, University of Novi Sad, Serbia.
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Disseminated Histoplasmosis with Miliary Histoplasmosis, Neurohistoplasmosis, and Histoplasma capsulatum Bacteremia in Probable Neurosarcoidosis. Case Rep Med 2018; 2018:3162403. [PMID: 30651732 PMCID: PMC6311783 DOI: 10.1155/2018/3162403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 11/26/2018] [Indexed: 01/01/2023] Open
Abstract
Introduction Neurosarcoidosis, either isolated or as part of systemic sarcoidosis, is an uncommon entity and has diagnostic uncertainty. Treatment for neurosarcoidosis can increase the risk of infections, including fungal infections such as disseminated histoplasmosis. Neurosarcoidosis may further predispose patients to infections of the central nervous system. Case Presentation A 54-year-old male with a history of probable neurosarcoidosis on methotrexate and infliximab presented with encephalopathy, hypoxia, and reported fevers. The patient was found to have disseminated histoplasmosis involving the lungs (miliary histoplasmosis), central nervous system (neurohistoplasmosis), and bloodstream. The Histoplasma capsulatum infection was treated with amphotericin and then voriconazole. Discussion Patients with neurosarcoidosis are suspected to have blood-brain barrier dysfunction. Lumbar puncture should be considered as part of initial investigative studies for infection. Empiric antimicrobial therapy for a patient with neurosarcoidosis on immunosuppressive agents may need to include antifungal agents.
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Zella S, Kneiphof J, Haghikia A, Gold R, Woitalla D, Thöne J. Successful therapy with rituximab in three patients with probable neurosarcoidosis. Ther Adv Neurol Disord 2018; 11:1756286418805732. [PMID: 30386436 PMCID: PMC6204624 DOI: 10.1177/1756286418805732] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 09/07/2018] [Indexed: 12/25/2022] Open
Abstract
Background Neurosarcoidosis occurs in about 5-15% of patients with sarcoidosis. Therapy with corticosteroids is generally accepted as the first-line medication, followed by various immunomodulating and cytotoxic agents or combined therapy. However, some patients show an unsatisfactory outcome or have adverse events and require novel treatment strategies. Methods We describe three patients with systemic sarcoidosis and central nervous system involvement who received CD20-targeted B-cell depletion with rituximab. Results Treatment with rituximab was well tolerated and followed by marked remission in patients nonresponsive to other immunosuppressive agents. Conclusion Rituximab may be used for patients with neurosarcoidosis who are nonresponsive to established treatment regimes.
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Affiliation(s)
- Samis Zella
- Department of Neurology at St. Josef Hospital, Medical Faculty of the Ruhr-University Bochum, Gudrunstr. 56, D-44791 Bochum, Germany Department of Neurology at Katholische Kliniken Ruhrhalbinsel Essen, Heidbergweg 22-24, D-45257 Essen, Germany
| | - Janina Kneiphof
- Department of Neurology at St. Josef Hospital, Medical Faculty of the Ruhr-University Bochum, Bochum, Germany
| | - Aiden Haghikia
- Department of Neurology at St. Josef Hospital, Medical Faculty of the Ruhr-University Bochum, Bochum, Germany
| | - Ralf Gold
- Department of Neurology at St. Josef Hospital, Medical Faculty of the Ruhr-University Bochum, Bochum, Germany
| | - Dirk Woitalla
- Department of Neurology at St. Josef Hospital, Medical Faculty of the Ruhr-University Bochum, Bochum, Germany Department of Neurology at Katholische Kliniken Ruhrhalbinsel Essen, Essen, Germany
| | - Jan Thöne
- Department of Neurology at Katholische Kliniken Ruhrhalbinsel Essen, Essen, Germany
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Scott AM, Yinh J, McAlindon T, Kalish R. Two cases of sarcoidosis presenting as longitudinally extensive transverse myelitis. Clin Rheumatol 2018; 37:2899-2905. [PMID: 29770929 DOI: 10.1007/s10067-018-4144-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 05/08/2018] [Indexed: 01/31/2023]
Abstract
Neurosarcoidosis is uncommon with an incidence of approximately 5 to 15%. Central nervous system involvement can be divided into brain and spinal cord neurosarcoidosis. Spinal cord sarcoidosis is extremely rare, occurring in less than 1% of all sarcoidosis cases. Its manifestations may include cauda equina syndrome, radiculopathy, syringomyelia, cord atrophy, arachnoiditis, and myelopathy or transverse myelitis. We highlight two cases of spinal cord sarcoidosis, each presenting with longitudinally extensive transverse myelitis, that demonstrate the dilemmas that physicians face with regard to diagnosis and treatment. Given its rarity and the diversity of possible manifestations, establishing the diagnosis of spinal cord sarcoidosis is often very difficult. Extensive evaluation must be conducted to rule out primary neurologic, primary rheumatologic, infectious, and neoplastic diseases. MRI often demonstrates hyperintensity on T2-weighted images and enhancement following gadolinium administration. CSF analysis most consistently shows a lymphocytic pleocytosis and elevated proteins. While these less invasive investigations may be helpful, the gold standard for diagnosis is biopsy of neurologic or non-neurologic tissue confirming the presence of non-caseating granulomas. Evidence-based guidelines for the treatment of transverse myelitis secondary to sarcoidosis are lacking due to its rarity; therefore, therapy is based on expert and anecdotal experience and usually consists of high doses of steroids in combination with various immunosuppressive agents. The use of infliximab in particular appears promising, but there is a need for further investigation into the ideal treatment regimen.
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Affiliation(s)
- Amanda Mary Scott
- Rheumatology Division, Tufts Medical Center, 800 Washington St, Boston, MA, 02111, USA.
| | - Janeth Yinh
- Rheumatology Division, Tufts Medical Center, 800 Washington St, Boston, MA, 02111, USA
| | - Timothy McAlindon
- Rheumatology Division, Tufts Medical Center, 800 Washington St, Boston, MA, 02111, USA
| | - Robert Kalish
- Rheumatology Division, Tufts Medical Center, 800 Washington St, Boston, MA, 02111, USA
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