Neurological presentation of sarcoidosis

CASE PRESENTATION: Woman, 49 years old, complaint of vertigo, diplopia, nausea, headache, global paresis, inappetence and intermittent febrile peaks in the afternoon. History of hospitalization for evaluation and complementary propedeutics, performed pulse therapy with corticosteroids for inflammatory disease of the unspecified central nervous system with good response to corticosteroids. After four months, it evolved with worsening of gait, imbalance, mental confusion, bilateral facial paresis, speech disorders, progressive dysphagia for liquids and solids, consumption syndrome and persistence of intermittent fever. Hospitalized again, diagnosed pan-hypopituitarism. Inguinal lymphnode biopsy was performed with finding of non-caseous epithelioid granulomas, configuring sarcoidosis with neurological presentation. Instituted immunosuppressive treatment with adjustments according to therapeutic response, and treatment with rituximab and corticosteroids was maintained.

DISCUSSION: Sarcoidosis consists of a systemic inflammatory disease that is characterized by the development of granulomas in any organ; however, neurosarcoidosis is a rare and difficult manifestation to diagnose. Although the most common manifestations in the central nervous system are cranial neuropathies, leptomeningeal disease, intraparenchymal lesions and myelitis, the disease can manifest itself as stroke, seizure, hypopituitary, neuropsychiatric symptoms and encephalopathy. We reported the case of a patient whose diagnostic investigation was challenging due to the multiple systemic and neurological manifestations.

FINAL COMMENTS: The diagnosis of neurosarcoidosis is challenging due to the fact that it is a chronic granulomatous disorder with no identified pathogen. The commonly most involved nerve injury is Bell's paralysis. Isolated lumbar and thoracic root lesions are also described, however sensory-motor neuropathy is rarely observed.