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Young M, Goldman-Yassen A, Anderson M, Thakral A, Dutt M, Wolf D, Morris M, Gombolay G. Neurosarcoidosis in children: A systematic review and summary of cases, imaging and management. J Neuroimmunol 2022; 371:577938. [PMID: 35944453 PMCID: PMC9703361 DOI: 10.1016/j.jneuroim.2022.577938] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 07/18/2022] [Accepted: 07/28/2022] [Indexed: 10/16/2022]
Abstract
Neurosarcoidosis is a rare disorder in children. We identified 30 pediatric NS cases through a systematic review. Twenty-one (70%) had systemic sarcoidosis with 30% having primary neurosarcoidosis. Eyes (37%), lymph nodes (37%) and lungs (30%) were most commonly involved. Isolated neurosarcoidosis were more likely in children (30%) than in adults (6%, p = 0.0005). Seizures and optic neuritis were also more common in children than adults (33% vs 14%, p = 0.002; and 30% versus 6%, p = 0.008, respectively). Evaluation, imaging, laboratory findings, and treatments are discussed. Additional research, including multi-center studies, is needed.
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Affiliation(s)
- Morgan Young
- Lincoln Memorial University-DeBusk College of Osteopathic Medicine; 6965 Cumberland Gap Pkwy, Harrogate, TN 37752, USA.
| | - Adam Goldman-Yassen
- Emory University School of Medicine, Departments of Radiology and Imaging Sciences & Pediatrics, and Children's Healthcare of Atlanta, Department of Radiology, 1405 Clifton Road NE, Atlanta, GA, USA.
| | - Monique Anderson
- Department of Neurology, Emory University School of Medicine, 201 Dowman Dr., Atlanta, GA 30322, USA.
| | - Amit Thakral
- Emory University, Children's Healthcare of Atlanta: Pediatrics Institute; Division of Pediatric Rheumatology, 1400 Tullie Road 8(th) Floor, Atlanta, GA 30329, USA.
| | - Monideep Dutt
- Emory University, Children's Healthcare of Atlanta: Pediatrics Institute; Division of Pediatric Neurology, 1400 Tullie Road 8(th) Floor, Atlanta, GA 30329, USA.
| | - David Wolf
- Emory University, Children's Healthcare of Atlanta: Pediatrics Institute; Division of Pediatric Neurology, 1400 Tullie Road 8(th) Floor, Atlanta, GA 30329, USA.
| | - Morgan Morris
- Emory University, Children's Healthcare of Atlanta: Pediatrics Institute; Division of Pediatric Neurology, 1400 Tullie Road 8(th) Floor, Atlanta, GA 30329, USA.
| | - Grace Gombolay
- Emory University, Children's Healthcare of Atlanta: Pediatrics Institute; Division of Pediatric Neurology, 1400 Tullie Road 8(th) Floor, Atlanta, GA 30329, USA.
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Shields R, Sagan O, Roebke L, Vander Maten J, Shah S, Chang G, Ibrahim D, Naz S. Rare case of multifocal extradural and intramedullary neurosarcoidosis without pulmonary involvement: a case report and literature review. Spinal Cord Ser Cases 2021; 7:89. [PMID: 34584071 PMCID: PMC8477626 DOI: 10.1038/s41394-021-00450-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/14/2021] [Accepted: 09/15/2021] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Ryan Shields
- College of Medicine and Life Sciences, The University of Toledo, Toledo, OH, USA.
| | - Olivia Sagan
- College of Medicine and Life Sciences, The University of Toledo, Toledo, OH, USA
| | - Logan Roebke
- College of Medicine and Life Sciences, The University of Toledo, Toledo, OH, USA
| | - Josh Vander Maten
- College of Medicine and Life Sciences, The University of Toledo, Toledo, OH, USA
| | - Shailen Shah
- College of Medicine and Life Sciences, The University of Toledo, Toledo, OH, USA
| | - George Chang
- Department of Pathology, The University of Toledo, Toledo, OH, USA
| | - Dalia Ibrahim
- Department of Pathology, The University of Toledo, Toledo, OH, USA
| | - Sumayya Naz
- Department of Neurology, The University of Toledo, Toledo, OH, USA
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Recurrence of Epidural Spinal Sarcoidosis. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2021; 5:01979360-202107000-00008. [PMID: 34270509 PMCID: PMC8288909 DOI: 10.5435/jaaosglobal-d-21-00086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/20/2021] [Indexed: 11/21/2022]
Abstract
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.
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Villacis-Nunez DS, Thakral A. Pituitary Sarcoidosis in a Pediatric Patient Successfully Treated With Adalimumab and Methotrexate. J Investig Med High Impact Case Rep 2021; 9:23247096211012191. [PMID: 33928822 PMCID: PMC8114318 DOI: 10.1177/23247096211012191] [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] [Indexed: 11/15/2022] Open
Abstract
Neurosarcoidosis is a rare phenomenon in the pediatric population, with only a few cases reported in the literature worldwide. While hypothalamo-pituitary involvement is known to occur, direct infiltration of the pituitary gland and isolated anterior pituitary dysfunction without diabetes insipidus is seldom observed. A high index of suspicion is required for diagnosis of neurosarcoidosis, and treatment can be challenging due to lack of standardized guidelines. We present the case of a 17-year-old female with known sarcoidosis of the lacrimal glands, who developed severe headache and neurologic symptoms secondary to granulomatous infiltration of the pituitary gland and infundibulum due to neurosarcoidosis. She was successfully treated with corticosteroids, methotrexate, and adalimumab, with complete radiologic resolution. This is the first documented pediatric case of neurosarcoidosis with radiologic granulomatous infiltration of the pituitary gland, manifesting as partial anterior hypopituitarism, in the form of central hypothyroidism, without diabetes insipidus.
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Affiliation(s)
| | - Amit Thakral
- Children's Healthcare of Atlanta, Emory University, Atlanta, GA, USA
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A rare case of spinal epidural sarcoidosis: case report and review of the literature. Acta Neurol Belg 2021; 121:415-420. [PMID: 31297669 DOI: 10.1007/s13760-019-01189-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/02/2019] [Indexed: 12/16/2022]
Abstract
Sarcoidosis is a rare systemic disease characterized by growth and organization of inflammatory cells in a granuloma. Granulomas can localize in any parts of the human body. The main localization is represented by lungs, lymph nodes, eyes and skin. Any organ, however, can be affected. Central nervous system (CNS) represents a rare localization of sarcoidosis, in fact, only 1% of patient with sarcoidosis present brain and/or spinal cord localization of the granulomas associated with this disease. This condition takes the name of Neurosarcoidosis. Its diagnosis and management pose a significant challenge, as its clinical manifestation and appearance in imaging studies are difficult to distinguish from more common lesion of the spinal cord. In this paper, we present the case of a 45-year-old woman who presented back pain associated with neurologic signs of myelopathy. Spinal cord MRI documented a T2 hyperintense signal around medullary conus. She underwent a gross total removal of the lesion. Histopathological examination revealed spinal sarcoidosis. Next total body CT scan did not show other localization of the disease. The aim of the present paper is to report a very rare case of spinal epidural sarcoidosis, actually only five cases have been described, without other localization of the disease. The present article underlines the difference between this forms of spinal sarcoidosis compared to intradural extramedullary and intramedullary spinal sarcoidosis.
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Khairy S, Alharbi NA, Alaglan A, Sufiani FA, Alkhani A. Cervical epidural neurosarcoidosis: A case report and literature review. Surg Neurol Int 2020; 11:133. [PMID: 32547820 PMCID: PMC7294160 DOI: 10.25259/sni_174_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 05/01/2020] [Indexed: 11/06/2022] Open
Abstract
Background: Neurosarcoidosis is a rare disease. In the spine, it commonly presents as an intramedullary lesion. Epidural spinal lesions are extremely rare. Case Description: A 29-year-old patient presented with a 22-month history of progressive neck, upper limb pain, and myelopathy. The cervical MRI showed a large epidural mass infiltrating the paraspinal soft tissue. After an open biopsy, the diagnosis of neurosarcoidosis was established and was followed-up by appropriate medical management. Conclusion: To manage cervical epidural neurosarcoidosis, first, you must obtain a tissue diagnosis and then follow with appropriate medical management.
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Affiliation(s)
- Sami Khairy
- Division of Neurosurgery, Department of Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - N A Alharbi
- Division of Neurosurgery, Department of Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Abeer Alaglan
- Division of Neurosurgery, Department of Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Fahd Al Sufiani
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,Department of Pathology and Laboratory Medicine, King Abdulaziz Medical City, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia
| | - Ahmed Alkhani
- Division of Neurosurgery, Department of Surgery, Ministry of the National Guard - Health Affairs, Riyadh, Saudi Arabia.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.,King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Abstract
Sarcoidosis is a systemic multisystem inflammatory disease of unknown etiology. The disease is characterized by formation of non-caseating granulomas. The most common presentation is bilateral hilar lymphadenopathy and lung infiltration, but the disease is very heterogeneous, with an unpredictable clinical course. Musculoskeletal manifestations are common. Bone involvement is less frequent, and usually occurs in patients with chronic multisystem course of the disease. They are most commonly found in the phalanges of hands and feet, and are usually bilateral. The skull, long bones, ribs, pelvis, and axial skeleton may also be affected. Osseous involvement may be asymptomatic but in some cases can cause a severe disability. Imaging techniques are important for diagnosis. Radiological investigations revealed sclerotic or destructive lesions (involving also joints), cystic and punched out lesions and cortical abnormalities. Biopsy is required for differential diagnosis with respect to malignancy. Treatment is a part of systemic therapy and is not needed in all cases. Glucocorticoids and TNF-α antagonists are used for management.
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Longo M, Gelfand Y, Kinon MD, Pullman J, Yassari R. Multifocal Epidural Neurosarcoidosis Causing Spinal Cord Compression: A Case Report. Cureus 2019; 11:e4177. [PMID: 31093476 PMCID: PMC6502289 DOI: 10.7759/cureus.4177] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We describe a rare case of multifocal extramedullary epidural neurosarcoidosis that presented with myelopathy without motor deficits and perform a literature review for previous cases of epidural neurosarcoidosis. A 46-year-old woman presented with lower back pain, urinary incontinence, gait disturbance, and sensory loss without motor deficits. Spine magnetic resonance imaging (MRI) showed multiple epidural lesions, the largest causing spinal cord compression at the T5 level. A computed tomography (CT)-guided biopsy of the dominant lesion showed noncaseating granulomas consistent with neurosarcoidosis. She was treated with a course of dexamethasone and discharged home after a 10-day hospital course. She was discharged home on oral prednisone taper over a four-month period. At her latest follow-up, she is neurologically intact and gainfully employed. This case demonstrates that certain cases of epidural neurosarcoidosis causing spinal cord compression may be treated with medical therapy alone in the absence of severe neurological deficits.
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Affiliation(s)
- Michael Longo
- Neurosurgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, USA
| | - Yaroslav Gelfand
- Neurosurgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, USA
| | - Merritt D Kinon
- Neurosurgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, USA
| | - James Pullman
- Neurosurgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, USA
| | - Reza Yassari
- Neurosurgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, USA
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