Abstract | November 8, 2021
An Atypical to Silent Intracranial Granuloma
Learning Objectives
- It is very important to think of Neurosarcoidosis with any kind of neurological symptoms even if it is very vague in presentation in a patient with history of symptomatic or asymptomatic sarcoidosis;
- Prompt treatment can result in better prognosis;
- Treatment with low dose steroids for sarcoidosis can aggravate other forms of sarcoidosis such as neurosarcoidosis.
Neurosarcoidosis is a chronic disease characterized by inflammation of the central nervous system, the leptomeninges and formation of granulomas.1 It causes destruction of myelin surrounding the axons reducing body function. It is present in only 7% of sarcoidosis cases.2
We are presenting a 60-year-old male with a past medical history of pulmonary sarcoidosis and granulomatous uveitis proven by biopsy, on chronic low-dose steroid which were started recently due to dyspnea on exertion. He presented to Emergency Department after a brief episode of expressive aphasia at home that resolved in 10 minutes. He presented to the hospital 24 hours later and denied fever, chills, headache, blurry vision, weakness, and focal neurological deficits. His physical exam, labs, CT of the brain, lumbar puncture were all unremarkable. Neurology was consulted and MRI was done which showed abnormal leptomeningeal enhancement and nodularity involving the right frontal region. A biopsy of the brain granuloma was pursued, and results showed small non caseating granulomas in right frontal dura (frozen section) and small leptomeningeal non caseating granulomas in the right frontal arachnoid and brain tissue diagnostic of neurosarcoidosis. He was started on levetiracetam and dexamethasone. He remained asymptomatic during his course at the hospital till date.
The most frequent manifestation of neurosarcoidosis is facial nerve palsy, optic neuritis, neuroendocrine dysfunction, peripheral neuropathy and other myopathies.3 Most cases of neurosarcoidosis are rapidly progressive accounting for poor prognosis without treatment. Not many asymptomatic cases with atypical presentations have been documented. It is important to think about neurosarcoidosis in a patient with history of sarcoidosis, with even a brief episode of neurological symptoms. A full work up should be done so prompt treatment with steroids or imunomodulatory therapies can result in better prognosis.4
References and Resources
- Neurosarcoidosis. (n.d.). Cedars Sinai. Retrieved July 18, 2021, from https://www.cedars-sinai.org/health-library/diseases-and-conditions/n/neurosarcoidosis.html
- Mayock RL, Bertrand P, Morrison LE, Scott JH. Manifestations of sarcoidosis. Am Med J 1963; 35: 67±89.
- Stern BJ, Krumholz A, Johns C, Scott P, Nissim J. Sarcoidosis and its neurological manifestations. Arch Neurol Psychiatry 1985; 42: 909±917.
- Gibson GJ, Prescott RJ, Muers MF, et al. British Thoracic Society Sarcoidosis study: effects of long term corticosteroid treatment. Thorax 1996; 51:238–247.
