Pulmonary Manifestations of Systemic Disease: Fellow Case Report Poster - Pulmonary Manifestations of Lung Disease |

Pulmonary Pathology Presenting as Paralysis: A Curious Case of Sarcoidosis FREE TO VIEW

Shibani Dogra, MD; Lilit Sargsyan, MD; Laura Nwogu, MD; Sujith Cherian, MD
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University of Texas Health Science Center at Houston/McGovern Medical School, Houston, TX

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):1056A. doi:10.1016/j.chest.2016.08.1163
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SESSION TITLE: Fellow Case Report Poster - Pulmonary Manifestations of Lung Disease

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Sarcoidosis is a multisystem disease of unknown etiology characterized by granuloma formation at sites of disease involvement. Neurosarcoidosis (NS) with mainly spinal cord involvement is an uncommon variant with a reported incidence of 0.43% of sarcoidosis cases. Due to its rarity, diagnosis can be a challenge.

CASE PRESENTATION: A 45 year-old African-American male with significant history of quadriplegia and neurogenic bladder attributed to multiple sclerosis (MS) was admitted with a urinary tract infection and hypothermia. A brain MRI showed new hypothalamic lesions, suggestive of sarcoidosis. A subsequent computed tomography (CT) of chest revealed mediastinal lymphadenopathy. Eight years prior to presentation, the patient was ambulatory and presented for progressive lower extremity weakness, which eventually led to a clinical diagnosis of MS. He was treated with cyclophosphamide and subsequently methotrexate, with no improvement in his functional status and progression to quadriplegia. CSF studies were not consistent with MS. Of note, review of a CT chest 6 years prior showed significant hilar lymphadenopathy, but no referral was made to pulmonary at that time. During the present admission, a bronchoscopy with endobronchial ultrasound with trans-bronchial needle aspiration revealed focal granulomas without evidence of infection. Given the clinical constellation, a diagnosis of NS was made. Our patient was initiated on steroids with mild improvement in his left upper extremity function.

DISCUSSION: Neural complications are present in only 5-10% of sarcoidosis cases. Typically those affected have significant systemic involvement, however 10% of cases have strictly neurologic involvement. In these patients, diagnosis is often delayed and can be mistaken for MS. First-line treatment for NS is 1-3 month trial of steroids. Other immunosuppressives such as azathioprine and hydroxychloroquine have shown promise in treating steroid-refractory NS. Low dose radiation has produced symptomatic benefits in case series.

CONCLUSIONS: This case highlights the protean nature of sarcoidosis and the danger of a premature closure bias. We learned the challenge of diagnosing sarcoidosis presenting exclusively with neurologic symptoms and the importance of early pulmonary and rheumatology involvement in such an atypical presentation and disease course.

Reference #1: Saleh S, et al. Sarcoidosis of the spinal cord: literature review and report of eight cases. Journal of the National Medical Association. 2006 Jun;98(6):965.

DISCLOSURE: The following authors have nothing to disclose: Shibani Dogra, Lilit Sargsyan, Laura Nwogu, Sujith Cherian

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