IMAGES IN NEUROLOGY
|Year : 2019 | Volume
| Issue : 1 | Page : 100-101
Neurosarcoidosis as a cause of longitudinally extensive myelitis: Neuroimaging clues for diagnosis
Ajay Asranna1, Aneesh Mohimen2, Roopa Rajan1, Muralidharan Nair1
1 Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
2 Department of Radiology, Airforce Command Hospital, Bengaluru, Karnataka, India
|Date of Web Publication||26-Dec-2018|
Dr. Ajay Asranna
Department of Neurology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Asranna A, Mohimen A, Rajan R, Nair M. Neurosarcoidosis as a cause of longitudinally extensive myelitis: Neuroimaging clues for diagnosis. Ann Indian Acad Neurol 2019;22:100-1
|How to cite this URL:|
Asranna A, Mohimen A, Rajan R, Nair M. Neurosarcoidosis as a cause of longitudinally extensive myelitis: Neuroimaging clues for diagnosis. Ann Indian Acad Neurol [serial online] 2019 [cited 2019 Jan 24];22:100-1. Available from: http://www.annalsofian.org/text.asp?2019/22/1/100/243786
| Introduction|| |
The clinical presentation of neurosarcoidosis is highly variable, and in rare instances, isolated spinal cord involvement may be the sole clinical manifestation. Extensive spinal cord involvement revealed on magnetic resonance imaging (MRI) of the spine is a key finding in spinal neurosarcoidosis. The presence of longitudinally extensive transverse myelitis, defined as lesions extending more than three vertebral segments on MRI spine, implies a wide differential diagnosis and neurosarcoidosis as a cause may be easily overlooked with grave consequences.
| Case Report|| |
A 48-year-old female presented to us with a history of symmetric, tingling paresthesia in the lower limbs for the past 9 months, which progressively ascended to involve the trunk and neck. On examination, she had loss of joint position and vibration sensations over the lower limbs and trunk, a sensory level at the mid-thoracic region, spasticity of bilateral lower limbs, and a positive Romberg's sign. MRI spine and brain showed longitudinally extensive T2 and fluid-attenuated inversion recovery hyperintensities, involving the posterior column with contrast enhancement [Figure 1]. MRI brain was normal. Causes of longitudinally extensive tract specific spinal cord lesions including neuromyelitis optica spectrum disorders (NMOSDs), paraneoplastic myelopathies, and Vitamin B12 deficiency were initially considered. Laboratory tests revealed normal levels of serum Vitamin B12 levels (1085 pg/ml; normal range 211–911 pg/ml) and serum copper (115 μg/dl; normal range 85–155 μg/dl) whereas serum aquaporin 4 antibody was negative. Screening for blood biomarkers for cancer including cancer antigen (CA)-125, Carcino Embryonic Antigen, CA 19-9, and alpha-feto protein were negative. Cerebrospinal fluid examination revealed five cells (all lymphocytes), mildly elevated proteins (57 mg/dl; normal 15–45 mg/dl), and normal sugar (66 mg/dl; normal 45–80 mg/dl). Computerized tomography (CT) of the thorax showed paratracheal, hilar, and subcarinal nodes in addition to the right upper lobe fibrosis. Serum angiotensin-converting enzyme levels were normal (50 U/L; normal range 8–53 U/L). CT-guided transthoracic biopsy of the mediastinal lymph nodes was then performed and histopathologic evaluation revealed noncaseating granulomas. Staining and polymerase chain reaction for Mycobacterium tuberculosis s negative. A diagnosis of systemic sarcoidosis with neurological involvement was made, and the patient was started on intravenous followed by oral steroids. She noted significant improvement in clinical symptoms with treatment.
|Figure 1: Magnetic resonance imaging spine T1 postcontrast showing multifocal areas of T2 hyperintensity with associated contrast enhancement (arrows), involving the posterior aspect of the spinal cord|
Click here to view
| Discussion|| |
Spinal cord involvement in sarcoidosis is a rare complication which affects about 0.43%–1% of patients and may even be the initial and solitary clinical presentation. Characteristic MRI findings in spinal neurosarcoidosis include longitudinally extensive spinal lesions with dorsal subpial contrast enhancement. A “trident” pattern has also been recently reported, but was not present in our patient. Longitudinally extensive spinal lesions may also be seen in NMOSD, paraneoplastic myelopathies, Vitamin B12 or copper deficiencies, and HIV myelopathy. However, the presence of dorsal subpial enhancement extending >2 vertebral segments is a distinct feature of neurosarcoidosis and is an important clue to differentiate it from other causes mentioned above. Flanagan et al. reported the presence of dorsal subpial enhancement as a reliable sign in differentiating neurosarcoidosis from NMOSD. The presence of this sign would therefore imply a prioritization of chest computed tomography (CT) or positron emission tomography CT to look for hilar lymph nodes. Extensive tract or gray matter-specific MRI changes are strongly associated with paraneoplastic myelopathies, particularly lung malignancies which may also show hilar lymphadenopathy. Neurosarcoidosis and paraneoplastic myelopathies may mimic each other closely, and a histological diagnosis becomes mandatory for crucial therapeutic and prognostic decision-making. Nevertheless, the presence of dorsal subpial enhancement as shown in [Figure 1] and [Figure 2] is a valuable clue which would favor a diagnosis of spinal neurosarcoidosis.
|Figure 2: Magnetic resonance imaging spine axial T1 postcontrast showing dorsal subpial contrast enhancement|
Click here to view
| Conclusions|| |
The presence of dorsal subpial enhancement on MRI spine is an important radiologic sign for diagnosing spinal neurosarcoidosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sohn M, Culver DA, Judson MA, Scott TF, Tavee J, Nozaki K, et al.
Spinal cord neurosarcoidosis. Am J Med Sci 2014;347:195-8.
Flanagan EP, Kaufmann TJ, Krecke KN, Aksamit AJ, Pittock SJ, Keegan BM, et al.
Discriminating long myelitis of neuromyelitis optica from sarcoidosis. Ann Neurol 2016;79:437-47.
Zalewski NL, Krecke KN, Weinshenker BG, Aksamit AJ, Conway BL, McKeon A, et al.
Central canal enhancement and the trident sign in spinal cord sarcoidosis. Neurology 2016;87:743-4.
Trebst C, Raab P, Voss EV, Rommer P, Abu-Mugheisib M, Zettl UK, et al.
Longitudinal extensive transverse myelitis – It's not all neuromyelitis optica. Nat Rev Neurol 2011;7:688-98.
Flanagan EP, McKeon A, Lennon VA, Kearns J, Weinshenker BG, Krecke KN, et al.
Paraneoplastic isolated myelopathy: Clinical course and neuroimaging clues. Neurology 2011;76:2089-95.
[Figure 1], [Figure 2]