Sarcoidosis is a multisystem inflammatory disorder characterized by granuloma formation, with 5% of patients developing neurosarcoidosis treated with immunosuppressants. We describe a case of a 38-year-old African-American male who presented to the hospital following a motor vehicle trauma. Further history indicated progressive cognitive decline over eight months.
MRI showed diffuse, nodular leptomeningeal enhancement of the brain and spine, consistent with neurosarcoidosis. CT chest showed hilar lymphadenopathy. Lumbar puncture results showed elevated cerebrospinal fluid (CSF) Angiotensin-converting enzyme (ACE). Lung biopsy revealed non-necrotizing granulomas, consistent with sarcoidosis and he was started on an aggressive outpatient immunosuppression regimen of high dose oral prednisone and azathioprine.
He was admitted to the hospital one month later with intractable vomiting. He was given intravenous methylprednisolone for suspected progression of neurosarcoidosis but developed rapidly progressive quadriplegia and respiratory failure. MRI brain showed a new 16 mm ovoid lesion in the right basal ganglia with peripheral enhancement and restricted diffusion. MRI cervical spine showed a similar enhancing intramedullary lesion with restricted diffusion from C1 to C4.
A brain biopsy was performed on the right basal ganglia lesion resulting in purulent drainage that later grew Streptococcus anginosus. He also underwent a laminectomy and surgical wash out of the cervical spine abscess. Corticosteroids were tapered and the patient gradually improved with antibiotics, regaining partial motor and sensory function in all four extremities.