A Case of Systemic Sarcoidosis presenting with UMN Paraparesis and Neuropsychiatric Manifestations

Abstract

Introduction: Sarcoidosis is a multiorgan granulomatous disease of unknown etiology. Neurological sarcoidosis is a rare manifestation of this disease and occurs in approximately 5 to 10% of patients.

Common syndromes include cranial mononeuropathy, neuroendocrine dysfunction, focal or multifocal encephalopathy, myelopathy, aseptic meningitis, peripheral neuropathy and myopathy.

Case summary: We present a case report of a 43 years old female who presented with chief complaints of bilateral lower limb weakness for two months and altered sensorium for one day. She also had history of lesions on nose and cheeks as well as swellings in fingers of hand and toe for around six months. She also developed decreased vision during the hospital stay. On examination, she had reduced power in bilateral lower limbs along with increased tone, atrophy of lower limbs and exaggerated reflexes. Plantar reflex was extensor bilaterally. There were no sensory or autonomic features. Contrast MRI of the brain and spine showed multifocal non enhancing T1 hypointense and T2/FLAIR hyperintense lesions involving the cortex and subcortical white matter with thickened and enhancing optic chiasma including the pre and retrochiasmatic region up to the right Lateral geniculate body, and leptomeningeal enhancement in brain along with Multiple ill defined areas of enhancement along the length of spinal cord in cervico-dorsal region with associated patchy areas of leptomeningeal enhancement. CECT Thorax reveled multiple subpleural, perifissural and peribronchovascular nodules nodules coalescing around the central bronchovascular structures, smooth interlobular septal thickening in bilateral lung fields and multiple discrete and confluent bilateral hilar and mediastinal lymph nodes with some of them showing calcifications within and a few showing heterogenous enhancement. Biopsy of skin lesion showed granulomas. A diagnosis of Systemic sarcoidosis with neurological involvement was made and treated with IV methylprednisolone pulse followed by oral steroids. The patient showed significant clinical improvement.

Conclusion: This case highlights the importance of considering the differential diagnosis of sarcoidosis in patients presenting with myelopathies and other neurological features, especially with the involvement of other systems.