Case Presentation: A 42-year-old male with a history of T2DM, subacute bilateral LE weakness and paresthesia presented with UTI, urinary retention and anejaculation. One month prior to admission the patient was taken to the ED after a fall with worsening bilateral lower extremity weakness. An MRI of the lumbosacral spine was performed which showed an L5-S1 disk protrusion with S1 nerve root impingement and he was discharged from the ED. The patient returned to the ED with complaints of dysuria and difficulty voiding. He also reported sexual dysfunction as he was unable to ejaculate for the last 2 months. Upon examination he was found to have 4/5 BL lower extremity weakness as well as a positive Babinski’s sign. An MRI of the Thoracic spine showed diffuse edema and expansion of the thoracic spinal cord from C7- T7 levels with increased T2 signal. Present were underlying areas of nodular and patchy enhancement. A CT scan of the chest was performed to assess for possible lymphadenopathy which showed extensive enlarged mediastinal lymph nodes. A biopsy of a lymph node showed a granulomatous inflammatory process consistent with sarcoidosis. The patient was subsequently started on high dose steroids and after showing mild improvement, was discharged home.Discussion: Sarcoidosis is a multisystem disorder of unknown etiology characterized by the accumulation of non-caseating granulomas in involved tissues. Neurosarcoidosis represents just 5 % of all patients with sarcoidosis and with less than 1% of patients having spinal cord sarcoidosis. The most commonly presenting symptom of neurosarcoidosis is cranial nerve deficit, with only 10% of the patients presenting with myelopathy. Diagnosing neurosarcoidosis can be challenging as no single serum or imaging test is specific or sensitive enough for a conclusive diagnosis. Often diagnosis is via an extra-neural biopsy of a granuloma since a biopsy of the brain, spinal cord or meninges can be technically difficult and poses greater risk to the patient. No randomized, double blind treatment trials have been performed for neurosarcoidosis. The current treatment recommendation is administering an initial high dose of steroids with immunosuppressive therapy for chronic/recurrent neurosarcoid.
Conclusions: As demonstrated in this case it is important for the inpatient team to isolate and localize the CNS lesion via a thorough history and examination of patients presenting with new onset myelopathy. Spinal cord sarcoidosis is an uncommon cause of myelopathy but should be considered in the differential diagnosis in patients with new spinal cord lesions. Once imaging establishes the location of the lesion, the gold standard for diagnosis is a biopsy of the neuronal tissues though an extra-neuronal biopsy is often used.