Neurosarcoidosis presenting as longitudinally extensive myelitis: Diagnostic assessment, differential diagnosis, and therapeutic approach

The Value of the "Trident Sign" and Flow Cytometry in Suspecting Spinal Cord Sarcoidosis: A Case Report and a Flow Chart of Diagnostic Imaging in Longitudinally Extensive Transverse Myelitis (LETM)

The diagnosis of sarcoidosis-related longitudinally extensive transverse myelitis (LETM) is challenging, requiring the exclusion of mimicking conditions along with histopathological confirmation of the diseases affecting the spinal cord. This report presents the case of a 68-year-old woman with complaints of low back pain and tingling dysesthesia in the limbs one month prior and finally developed paraparesis with the need for support from a third person for walking. Magnetic resonance imaging (MRI) of both the brain and spinal cord, total body computed tomography, lumbar puncture, flow cytometry of the cell sediment from cerebrospinal fluid (CSF), and whole-body 18-F-fluorodeoxyglucose positron emitting tomography (FDG-PET) assisted us to finalise the diagnosis. The presence of the "trident sign" in axial sequences of MRI is of exceptional value since it is a clue for sarcoidosis of the spinal cord. CSF flow cytometry may help clinicians to rule out lymphoma, and FDG-PET can help clinicians in identifying manifestations of sarcoidosis, which need to be biopsied so as to unveil the final diagnosis.

[Challenges of differential diagnosis in the verification of Behçet's disease with neurological manifestations]

Behçet's disease (BD) is an autoimmune vasculitis of unclear etiology characterized by a wide range of systemic manifestations. The nervous system is involved in approximately 10% of patients with BD (neuro-Behçet). Diagnosis of neuro-Behçet is challenging, especially in the case of BD onset with neurological manifestations, and is based on a combination of clinical, laboratory, and neuroimaging data. To verify the diagnosis of neuro-Behçet, a wide range of conditions with similar manifestations must be ruled out: multiple sclerosis, neuromyelitis optica spectrum disorder, neurosarcoidosis, and many rare autoimmune diseases (e.g., Cogan syndrome, Susac syndrome, Vogt-Koyanagi-Harada syndrome). This article presents a brief literature review highlighting the challenges of neuro-Behçet differential diagnosis and a clinical case of a 34-year-old male patient with a criteria-based diagnosis of BD with neurological manifestations.

Longitudinally extensive transverse myelitis as an initial manifestation of sarcoidosis: A rare case and its management

Key Clinical Message

Sarcoidosis-induced LETM represents a rare but life-threatening neurological manifestation of sarcoidosis, characterized by spinal cord inflammation, and associated neurological deficits. Sarcoidosis should be included in the differential diagnosis of LETM, particularly in patients with no lung involvement. Prompt recognition and management are obligatory to optimize outcomes and prevent long-term disability.

Abstract

Sarcoidosis is a multisystem inflammatory granulomatous disorder characterized by the formation of noncaseating granulomas. Although sarcoidosis commonly affects the skin, lymph nodes, and lungs, neurological involvement of sarcoidosis has also been reported. Longitudinally extensive transverse myelitis (LETM) is a rare but well-documented serious manifestation of neuroscoidosis. We report a case of LETM caused by sarcoidosis in a 53-year-old male who presented with progressive bilateral lower extremity weakness, urinary retention, and paresthesia. Laboratory evaluations revealed elevated inflammatory markers. Magnetic resonance imaging of the spine showed hyperintense signals consistent with transverse myelitis. Cerebrospinal fluid analysis revealed lymphocytic pleocytosis and elevated protein levels. Chest computed tomography showed hilar lymphadenopathy. A biopsy of the intrathoracic lymph node showed noncaseating granulomas consistent with sarcoidosis. A diagnosis of sarcoidosis-induced LETM was made after ruling out all other possible etiologies. His condition improved gradually after starting high-dose prednisone, mycophenolate, and rehabilitation strategies. Our case underscores the importance of prompt diagnosis and management of sarcoidosis-induced LETM and highlights that sarcoidosis must be included among differential diagnoses of LETM, especially in cases with no lung involvement.

Neurosarcoidosis and Transverse Myelitis: Life-Threatening Manifestations of Sarcoidosis

Sarcoidosis, a systemic granulomatous disorder, typically involves the lungs, skin, and lymph nodes. Neurological manifestations are diverse and may include longitudinally extensive transverse myelitis (LETM), an uncommon inflammatory disorder of the spinal cord. We present a case of a 62-year-old female with LETM as the initial manifestation of sarcoidosis. The patient exhibited progressive bilateral lower extremity weakness, urinary retention, and sensory disturbances. Diagnostic workup revealed characteristic findings on spinal magnetic resonance imaging (MRI), cerebrospinal fluid analysis, and thoracic biopsy. Treatment with high-dose corticosteroids and subsequent immunomodulatory therapy resulted in significant improvement. Our case highlights the importance of including sarcoidosis in the differentials of LETM, particularly in patients with no respiratory manifestations.

Longitudinally Extensive Transverse Myelitis as a First Manifestation of Sarcoidosis

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.

Transverse myelitis caused by herpes zoster following COVID-19 vaccination: A case report

BACKGROUND

Transverse myelitis (TM) is characterized by sudden lower extremity progressive weakness and sensory impairment, and most patients have a history of advanced viral infection symptoms. A variety of disorders can cause TM in association with viral or nonviral infection, vascular, neoplasia, collagen vascular, and iatrogenic, such as vaccination. Vaccination has become common through the global implementation against coronavirus disease 2019 (COVID-19) and reported complications like herpes zoster (HZ) activation has increased.

CASE SUMMARY

This is a 68-year-old woman who developed multiple pustules and scabs at the T6-T9 dermatome site 1 wk after vaccination with the COVID-19 vaccine (Oxford/ AstraZeneca ([ChAdOx1S{recombinant}]). The patient had a paraplegia aggravation 3 wk after HZ symptoms started. Spinal magnetic resonance imaging (MRI) showed transverse myelitis at the T6–T9 Level. Treatment was acyclovir with steroids combined with physical therapy. Her neurological function was slowly restored by Day 17.

CONCLUSION

HZ developed after COVID-19 vaccination, which may lead to more severe complications. Therefore, HZ treatment itself should not be delayed. If neurological complications worsen after appropriate management, an immediate diagnostic procedure, such as magnetic resonance imaging and laboratory tests, will start and should treat the neurological complications.