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Shrestha K, Kleinschmidt-DeMasters BK, Ormond DR. Diagnostic challenges of neurosarcoidosis in non-endemic areas. Front Neurol 2024; 14:1220635. [PMID: 38274870 PMCID: PMC10809150 DOI: 10.3389/fneur.2023.1220635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/06/2023] [Indexed: 01/27/2024] Open
Abstract
Background Neurosarcoidosis (NS) is a challenging diagnosis, particularly when cases occur in low-prevalence, non-endemic geographic regions. In the United States, the highest incidence is in the Midwest and Northeast, compared to our Southwest location. While it is well known that NS may clinically and neuroradiographically mimic meningeal carcinomatosis, autoimmune or infectious pachymeningitis, neurosyphilis, or tuberculosis, diagnosis may be particularly challenging if systemic signs of sarcoidosis are lacking or unconfirmed or if dural-based masses are present. We reviewed our Colorado experience with NS cases, focusing our study on cases where NS represented the first histological confirmation of disease. Methods A search of departmental databases was conducted with the search term "neurosarcoidosis" to identify cases 1-2008 to 12-2019, inclusive of the given case numbers. Patients were only included if their clinical and neuroimaging features were unusual and only when a biopsy of the central nervous system (CNS) represented the first confirmed diagnosis of sarcoidosis. Results A total of 17 cases were identified, of which the biopsy of the CNS was used for the initial confirmation of the disease in 9 of them. The most unusual findings were two patients with dural-based masses, one of which had pure NS as the cause of meningioma-like lesions and the second of which had coexistent meningioma and intimately admixed non-necrotizing granulomas of NS. Conclusion NS with unusual features, especially in non-endemic areas, continues to yield diagnostic challenges for neurologists, neuroradiologists, and pathologists.
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Affiliation(s)
- Keshari Shrestha
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - B. K. Kleinschmidt-DeMasters
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States
- Department of Pathology, University of Colorado School of Medicine, Aurora, CO, United States
| | - D. Ryan Ormond
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, United States
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Deboutte I, Godts D, Van Lint M. Recurrent multiple eye muscle palsy as a first sign of sarcoidosis. GMS OPHTHALMOLOGY CASES 2023; 13:Doc21. [PMID: 38111471 PMCID: PMC10726560 DOI: 10.3205/oc000229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
Abstract
Purpose To report a case of (neuro)sarcoidosis presenting solely with recurrent cranial nerve palsies in a 57-year-old Caucasian female. Methods Case report with clinical imaging. Results A 57-year-old female first presented with a right sixth nerve palsy, which resolved spontaneously after 6 months. Three years later she was diagnosed with a sixth nerve palsy in the fellow eye followed by a complete palsy of the left third cranial nerve four months after. Medical history consisted of migraine and hypercholesterolemia. Further neurological and ophthalmic work-up was unrevealing at first. After repeated magnetic resonance imaging, an enhancing lesion in the left cavernous sinus was seen, which was initially diagnosed as a meningioma. However, imaging of the chest revealed an image of sarcoidosis, and the lesion and ophthalmoplegia of the left eye disappeared with systemic corticosteroid treatment. Discussion Sarcoidosis is the ultimate imitator and the possibility of neurosarcoidosis must be taken into account when presented with unexplained ophthalmoplegia. Neurosarcoidosis has imaging properties very similar to other diseases such as a meningioma, and misdiagnosis occurs easily. Spontaneous recovery of ophthalmoplegia can rarely occur in neurosarcoidosis.
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Affiliation(s)
- Isabel Deboutte
- Department of Ophthalmology, Antwerp University Hospital, Edegem, Belgium
- Medical Science Department, University of Antwerp, Belgium
| | - Daisy Godts
- Department of Ophthalmology, Antwerp University Hospital, Edegem, Belgium
| | - Michel Van Lint
- Department of Ophthalmology, Antwerp University Hospital, Edegem, Belgium
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Fröhlich K, Mrochen A, Wang R, Haupenthal D, Macha K, Siedler G, Knott M, Dörfler A, Schwab S, Winder K. Cerebral lesions sites in neurosarcoidosis: a lesion mapping study. J Neurol 2023; 270:5392-5397. [PMID: 37433894 PMCID: PMC10576719 DOI: 10.1007/s00415-023-11863-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND AND PURPOSE Sarcoidosis is a granulomatous disease of unknown etiology affecting the central nervous system in up to 15% of the patients. Diagnosis of neurosarcoidosis is very challenging due to the heterogeneity of its clinical manifestation. This study intended to evaluate the distribution of cerebral lesion sites and the potential presence of specific lesion clusters in neurosarcoidosis patients using voxel-based lesion symptom mapping (VLSM). METHODS Patients with neurosarcoidosis were retrospectively identified and included between 2011 and 2022. Cerebral lesion sites were correlated voxel-wise with presence and absence of neurosarcoidosis using non-parametric permutation test. Multiple sclerosis patients served as controls for the VLSM-analysis. RESULTS Thirty-four patients (mean age 52 ± 15 years) of whom 13 were diagnosed with possible, 19 with probable and 2 with confirmed neurosarcoidosis were identified. Lesion overlap of neurosarcoidosis patients demonstrated a distribution of white matter lesions in all brain areas, with a periventricular predilection similar to multiple sclerosis. In contrast to multiple sclerosis controls, no propensity for lesions in proximity of the corpus callosum was observed. Neurosarcoidosis lesions appeared smaller and lesion volume was lower in the neurosarcoidosis cohort. The VLSM analysis showed minor associations between neurosarcoidosis and damaged voxels in the bilateral frontobasal cortex. CONCLUSIONS The VLSM analysis yielded significant associations in the bilateral frontal cortex, suggesting that leptomeningeal inflammatory disease with following cortical involvement is a quite specific feature in neurosarcoidosis. Lesion load was lower in neurosarcoidosis than in multiple sclerosis. However, no specific pattern of subcortical white matter lesions in neurosarcoidosis was revealed.
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Affiliation(s)
- Kilian Fröhlich
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany.
| | - Anne Mrochen
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Ruihao Wang
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - David Haupenthal
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Kosmas Macha
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Gabriela Siedler
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Michael Knott
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Klemens Winder
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
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Morrison Z, Yeh MY, Hughes J. Diffuse mass-like dural-based neurosarcoidosis with concurrent leptomeningeal involvement: an unusual case presentation and review. Quant Imaging Med Surg 2023; 13:6343-6346. [PMID: 37711812 PMCID: PMC10498216 DOI: 10.21037/qims-22-1382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/20/2023] [Indexed: 09/16/2023]
Affiliation(s)
- Zachary Morrison
- Creighton University Arizona Health Education Alliance, Diagnostic Radiology, Phoenix, AZ, USA
- St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Mary Y. Yeh
- St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- School of Medicine, Phoenix Regional Campus, Creighton University, Phoenix AZ, USA
| | - Jeremy Hughes
- St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- Department of Neuroradiology, Barrow Neurological Institute, Phoenix, AZ, USA
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Liberio R, Kramer E, Memon AB, Reinbeau R, Feizi P, Joseph J, Wu J, Sriwastava S. Relevance of Medullary Vein Sign in Neurosarcoidosis. Neurol Int 2022; 14:638-647. [PMID: 35997361 PMCID: PMC9397064 DOI: 10.3390/neurolint14030052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/08/2022] [Accepted: 08/11/2022] [Indexed: 12/04/2022] Open
Abstract
Background: Central nervous system involvement is uncommon in patients with sarcoidosis. It remains a diagnostic challenge for clinicians, as there is a broad differential diagnosis that matches the presenting neurological signs. Often, the imaging findings also overlap with other disease entities. One understudied finding in patients with neurosarcoidosis is the presence of medullary vein engorgement on SWI imaging, termed the “medullary vein sign”, which has been postulated to be a specific sign for neurosarcoidosis. This study aims to provide an understanding of the diagnostic potential of the medullary vein sign. Methods: Thirty-two patients who presented with neurologic signs concerning for possible neurosarcoidosis were analyzed retrospectively for the presence of the medullary vein sign. Results: Out of these cases, 7 cases of definitive neurosarcoidosis cases were found based on other imaging signs, biopsy and CSF analysis; the remaining were classified into groups as possible (16), probable (5) and (4) cases of other infectious meningoencephalitis including 2 cases of autoimmune encephalitis. Seven patients among all of these cases were found to have the medullary vein sign on imaging, with five cases with confirmed and two cases from possible neurosarcoidosis. The sensitivity of the medullary vein sign in this study was 71.4%, and the specificity was 92.3%. Discussion: The benefits of improving diagnostic criteria for neurosarcoidosis include more rapid diagnosis leading to more prompt treatment, less exposure to potentially harmful antibiotics or antifungals, and less long-term neurological effects. Our results support that the medullary vein sign will potentially fill in the diagnostic gaps that have challenged the timely diagnosis of neurosarcoidosis. Conclusions: Our findings support that the medullary vein sign has a high specificity and should be included in the diagnostic criteria for neurosarcoidosis.
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Affiliation(s)
- Richard Liberio
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA
- Department of Neurology, West Virginia University, Morgantown, WV 26506, USA
| | - Emily Kramer
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA
- Department of Neurology, West Virginia University, Morgantown, WV 26506, USA
| | - Anza B. Memon
- Department of Neurology, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Ryan Reinbeau
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA
- Department of Neurology, West Virginia University, Morgantown, WV 26506, USA
| | - Parissa Feizi
- Department of Neuroradiology, West Virginia University, Morgantown, WV 26506, USA
| | - Joe Joseph
- Department of Neuroradiology, West Virginia University, Morgantown, WV 26506, USA
| | - Janet Wu
- Department of Neurology, West Virginia University, Morgantown, WV 26506, USA
| | - Shitiz Sriwastava
- School of Medicine, West Virginia University, Morgantown, WV 26506, USA
- Department of Neurology, West Virginia University, Morgantown, WV 26506, USA
- Department of Neuroradiology, West Virginia University, Morgantown, WV 26506, USA
- Department of Neurology, Wayne State University, Detroit, MI 48201, USA
- West Virginia Clinical and Translational Science Institute, Morgantown, WV 26506, USA
- Correspondence: ; Tel.: +1-304-581-1903
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