Progressive Cervical Myelopathy as Presentation of Sarcoidosis

Abstract

A 44-year-old African-American woman was admitted with four months of intermittent “shock-like” sensations in her chest radiating to both arms; she developed left arm weakness just prior to admission. A cervical spine magnetic resonance imaging (MRI) demonstrated intramedullary enhancement from C1 to T1 (Fig. 1 Panel a). Figure 1. Cervical spine magnetic resonance imaging (MRI) of a 44-year-old African-American woman. Panel a: MRI with gadolinium contrast 3 weeks prior to admission. Panel b: MRI with gadolinium contrast after 8 weeks of corticosteroid therapy. Neurologic examination showed 4/5 strength of left wrist flexors and extensors, decreased bilateral light touch and pinprick sensation from C5 to T5, and hyperalgesia bilaterally from T1 to T3. Chest x-ray showed hilar adenopathy. Serum angiotensin converting enzyme level was 191 U/L (normal 9–67). Lumbar puncture was remarkable for a protein of 54 mg/dl (normal 15–45) and glucose of 30 mg/dl (normal 45–80; serum glucose 106). Transbronchial biopsy showed non-caseating granulomas. Sarcoidosis is an idiopathic inflammatory disease characterized by non-caseating granulomas affecting any organ. Neurologic involvement occurs in 5–17 % of sarcoidosis patients, with 0.43 % having spinal cord involvement.1 The most common cerebrospinal fluid findings are elevated protein and hypoglycorrhachia, presumably a manifestation of chronic meningeal inflammation.2 Owing to the invasive nature of spinal cord biopsy, neurosarcoidosis is often diagnosed with extraneural tissue and the appropriate clinical syndrome.3,4 Treatment generally includes immunosuppressive agents. This patient’s neurological deficits and radiographic abnormalities improved with corticosteroids (Fig. ​(Fig.11 Panel b).