A stroke—or something else?
The patient—who’d had a CVA the year before—was experiencing numbness and weakness in her right leg and foot, and had an increasingly unsteady gait. Initial lab work provided no clues.
The prognosis with sarcoidosis can vary widely. Case studies show that two-thirds of patients may have a nonrecurring illness. Among the remaining one-third, the disease course may be relapsing-remitting or progressive. When confronted with an acute neurologic event, consider recurrent sarcoidosis and coordinate care between specialists. Also, take steps to prevent complications related to prolonged steroid use.
TABLE 2
Treatment of neurosarcoidosis3
| Medication* | Side effects | Comments |
|---|---|---|
| Methylprednisolone | Hyperglycemia | |
| Prednisone | Osteoporosis, hyperglycemia, hypertension, diabetes, glaucoma, cataracts, psychosis, Cushing’s syndrome | Taper as able. Concomitant use of cytotoxic agents may facilitate taper. Monitor glucose and give calcium/vitamin D prophylaxis |
| Methotrexate | Anemia, neutropenia, liver damage | Weekly dosing well tolerated. Give folic acid 1 mg/d. Monitor liver function tests periodically |
| Cyclosporine | Renal insufficiency, hypertension | |
| Azathioprine | Anemia, neutropenia, liver damage | |
| Cyclophosphamide | Cystitis, neutropenia | Monitor urine monthly for microscopic hematuria |
| Hydroxychloroquine | Retinopathy, hypoglycemia, ototoxicity, myopathy, cardiomyopathy, neuropathy | Refer for eye exams every 3-6 months. May be useful to counteract hyperglycemic effect of steroids |
| Infliximab | Fever, headache, dizziness, flushing, abdominal pain, dyspepsia, myalgia, arthralgia, polyneuropathy | Screen for tuberculosis before starting treatment. Contraindicated in patients with congestive heart failure |
| *For dosing details, consult a neurologist or rheumatologist | ||
Improvement for our patient
Based on cerebrospinal fluid study results, a positive peripheral lymph node biopsy, and the exclusion of other diagnoses, we regarded the diagnosis of sarcoidosis as highly probable and initiated high-dose intravenous corticosteroids. Over several weeks, our patient gradually improved with physical therapy and was walking unassisted at the time of discharge from a hospital-based rehabilitation unit. Repeat MRI scans showed a reduction in the size of her intradural lesions, and we slowly tapered her steroids.
CORRESPONDENCE
Hillary R. Mount, MD, 2123 Auburn Avenue,#340, Cincinnati, OH 45219; hillary.mount@thechristhospital.com
