Case Presentation: A 26 year old previously healthy male presented with complaints of right leg weakness and urinary retention.  Three weeks prior, he experienced back pain in the setting of a lifting injury at work and was treated symptomatically for low back strain.  Two weeks later, he began having right leg weakness and tingling which acutely worsened three days prior to admission when he also began having urinary hesitancy and straining.  On presentation to the ED he was unable to bear weight on the right leg and required a Foley catheter for urinary retention > 1L.  Physical exam was significant for 4+/5 strength in the left leg and 1/5 on the right.  MRI revealed multifocal intramedullary enhancement of the thoracic cord at T3-T6 with extensive T2 signal throughout the cervical and thoracic cord as well as enhancement involving the fornix and septum pellucidum.  The radiologic differential diagnosis included lymphoma, sarcoidosis, and tuberculosis.  CT of the chest showed mildly prominent mediastinal and hilar lymph nodes.  Serum studies including a TB workup were unremarkable.  CSF studies were significant only for mildly elevated protein.  Over several days he had fluctuating lower extremity strength with involvement of both legs.  Tissue was required for diagnosis; mediastinal lymph node biopsy was judged to be less risky than spinal cord biopsy.  Therefore, bronchoscopy with endobronchial ultrasound was performed.  Cytology revealed non-caseating granulomatous inflammation consistent with sarcoidosis.  He was started on IV methylprednisolone 1g daily with improvement in his symptoms over four days and subsequently discharged home with outpatient Neurology follow-up.

Discussion: Neurologic complications occur in 5-15% of patients with sarcoidosis; however, neurosarcoidosis in the absence of systemic disease presents a diagnostic challenge due to its protean, non-specific manifestations.  The annual incidence of isolated neurosarcoidosis is less than 0.2/100,000 among Caucasians.  The most common manifestation is cranial nerve palsy.  Spinal lesions are uncommon, occurring in 5-10% of neurosarcoidosis.  Spinal sarcoidosis has a variable clinical presentation and can include paresthesias, weakness, paraperesis, radicular syndromes, cauda equina syndrome, and neurogenic urinary symptoms among others.  Interestingly, in a case series of 17 patients with spinal sarcoidosis, only 4 had been diagnosed with sarcoidosis prior to spinal involvement.  We believe that our patient’s preceding lower back injury was a red herring and did not contribute to his presentation.

Conclusions: Spinal neurosarcoidosis is a rare cause of subacute paraplegia and should be considered in any patient presenting with weakness and paresthesias regardless of a preexisting diagnosis of sarcoidosis.  Furthermore, myelopathy or radiculopathy in young men should not be attributed to lower back injury without first excluding other serious causes.