Tahreem Hashmi, DO
Resident Physician PGY2
Memorial Healthcare System
Cooper City, Florida, United States
Joanne M. Delgado-Lebron, MD
Attending Physician
Memorial Hospital System
Hollywood, Florida, United States
John Paul Mauriello, DO
Resident Physician PGY2
Memorial Healthcare System
Dania, Florida, United States
A 46-year-old female, recently diagnosed with pulmonary sarcoidosis, presented with progressively worsening bilateral lower extremity weakness, neuropathic pain, and urinary incontinence. Neurological examination revealed profound right greater than left lower limb weakness, hypoesthesia, hyperreflexia, clonus, and upgoing plantar responses, raising concern for myelopathy. MRI of the thoracic spine revealed significant cord compression from T5-T10, longitudinally extensive intramedullary enhancement and multiple disc herniations from T4-T10. Clinical data and ancillary testing led to the diagnosis of probable neurosarcoidosis. After high-dose methylprednisolone course, repeat MRI demonstrated improvement in intramedullary enhancement. Then, she underwent T5-T9 decompression with T3-T10 posterior instrumented fusion to prevent worsening of thoracic kyphosis and further cord compression due to six consecutive levels of thoracic disc herniations. After acute inpatient rehabilitation, she made significant improvements in function, achieving modified independence in mobility and activities of daily living.
Discussions: Nervous system involvement occurs in 5-15% of sarcoidosis cases, with spinal cord involvement in approximately 7%. Sarcoidosis-associated myelopathy (SAM) is a rare but serious manifestation that presents a diagnostic challenge due to overlapping features with other spinal cord disorders including spondylotic myelopathy. Definitive diagnosis of neurosarcoidosis can be difficult, as biopsy is often not feasible and poses a high risk. In such cases, clinical data and ancillary testing become essential for prompt diagnosis and treatment to prevent permanent neurological deficits.
Conclusions: This case underscores the importance of maintaining a high index of suspicion for SAM. Early recognition and timely intervention, as demonstrated, are critical for preventing long-term neurological deficits. This case also highlights the importance that although neurosarcoidosis is an uncommon cause of myelitis, it should be included in the differential diagnosis of patients with a myelitis of unknown etiology.
