Optic Foramen Enlargement Caused by Sarcoid Granuloma

Abstract

The nervous system is affected in more than 5 per cent of patients with sarcoid, according to the combined series reviewed by Mayock et al. (14), and the figure approaches 30 per cent if spinal fluid abnormalities are taken as evidence (9). Sarcoid granulomas may involve the brain and spinal cord, the meninges, or the cranial and peripheral nerves separately or in combination, producing protean clinical manifestations (1, 4, 5, 9). Large granulomas may simulate neoplasm both clinically and radiographically (16). Facial palsy is the commonest cranial neuropathy (2, 9, 10). Next in frequency of involvement is the optic nerve (2): papillitis of one or both may occur, possibly associated with iridocyclitis. Granuloma of the optic nerve has occasionally been reported (11). A sarcoid granuloma producing unilateral enlargement of the optic canal has not previously been described and forms the basis for this report. Case Report B. M., an 18-year-old Negro girl, was admitted to the Los Angeles County General Hospital on Nov. 29, 1964, with a complaint of decreasing vision in the right eye of four to five months duration and frontal headaches for one month. The patient was first aware of a visual problem when she failed a driver's test. Physical examination revealed a nervous, uncooperative female. Vital signs were normal. Examination of the right eye disclosed a 3 mm proptosis, widening of the palpebral fissure, visual acuity of 20/200 with a large central scotoma, and optic atrophy. The pupils were round, equal in size, and reacted normally to light and accommodation. The left eye was normal. The remainder of the neurological and general physical examinations were negative. Lumbar puncture revealed normal pressure, protein, chloride, and no cells. The hemogram, the blood urea nitrogen, urinalysis, and an electroencephalogram were normal, as were the serum calcium, phosphate, alkaline phosphatase, and the twenty-four-hour urine calcium excretion. Blood and spinal fluid serology and lupus erythematosus tests resulted in normal findings. The C-reactive protein was positive, and the latex fixation weakly reactive. An electrocardiogram showed nonspecific primary precordial T-wave abnormalities consistent with myocarditis, pericarditis, or diffuse ischemia. Skin tests for coccidioidomycosis, histoplasmosis, and tuberculosis (purified protein derivative, intermediate, tuberculin No.2) were negative. Serum protein electrophoresis disclosed normal total protein, decreased albumin, and an increased gamma globulin fraction (30.6 per cent). Routine radiographs of the chest, hands, and skull were normal. Optic foramen views (Fig. 1) revealed an abnormally rounded and eroded right optic canal measuring 6.0 × 7.0 mm. Right carotid angiography and pneumoencephalography, including autotomograms of the gas-filled suprasellar area, were negative. Craniotomy was performed on Dec. 14, 1964.2