Vertigo as a Predominant Manifestation of Neurosarcoidosis

Abstract

Sarcoidosis is a granulomatous disease of unknown etiology that affects multiple organ systems. Neurological manifestations of sarcoidosis are less common and can include cranial neuropathies and intracranial lesions. We report the case of a 21-year-old man who presented with vertigo and uveitis. Extensive workup including brain imaging revealed enhancing focal lesions. A lacrimal gland biopsy confirmed the diagnosis of sarcoidosis. The patient was initially treated with prednisone, which did not adequately control his symptoms, and then was switched to methotrexate with moderate symptomatic improvement. Our patient had an atypical presentation with vertigo as the predominant manifestation of sarcoidosis. Patients with neurosarcoidosis typically present with systemic involvement of sarcoidosis followed by neurologic involvement. Vertigo is rarely reported as an initial manifestation. This case highlights the importance of consideration of neurosarcoidosis as an entity even in patients that may not have a typical presentation or systemic involvement of disease.

Recurrent Bifacial Neuropathy in a Case of Steroid Responsive Neurosarcoidosis: A Case Report

“…However, it is nonspecifi c. About one-third of patients with NS will have normal CSF analysis fi ndings as was the situation in our present case (10). CSF analysis will be helpful in excluding CNS infections or malignancy (2,5,7). An elevated CSF protein level typically accompanies oligoclonal bands in patients with NS, but which was not found in this present case.…”

“…Contrast studies for the evaluation of leptomeninges, parenchyma, and cranial nerves is important (1-3,9). Whole body Gallium (Ga) scanning or fl uorodeoxyglucose PET scanning are ideal tests which were not performed on our patient and can be utilized to search the whole body for occult infl ammation or neoplasia and therefore fi nd suitable sites for biopsy (1,2). It is important to take note that whole body Gallium scanning is insensitive to central nervous system (CNS) lesions and shows uptake in only 5% of cases with CNS lesions, but may detect other systemic involvement in up to 45% of cases, and these cases usually have a concomitant CNS involvement (11).…”

“…A biopsy of these lesions is warranted. The sarcoid non-caseating granuloma may be found in all organs and tissues, including the nerve roots, peripheral, and central nervous systems (2)(3)(4)11).…”

“…Sarcoidosis is a rare, often misdiagnosed, infl ammatory multisystem disorder of unknown etiology with worldwide distribution (1,2). Neurosarcoidosis (NS) commonly affects the cranial nerves, hypothalamus, and pituitary gland, but also involves the meninges, parenchyma, brainstem, and spinal cord.…”

“…The 7th cranial nerve is the most commonly affected cranial nerve . Histopathologic fi ndings of non-caseating granulomatous infi ltration of the meninges and underlying parenchyma are most frequently seen at the base of the brain (2)(3)(4). The process is either subacute or chronic in nature mimicking other granulomatous lesions and neoplasms.…”