Background and aims: The diagnosis of spinal cord sarcoidosis can be particularly challenging when not accompanied by clinically overt systemic involvement. Herein we describe a rare case of longitudinally extensive spinal cord sarcoidosis incidentally disclosed during the diagnostic work-up for intermittent diplopia. Methods: The clinical presentation and diagnostic approach leading to the diagnosis of spinal cord sarcoidosis are presented Results: A 53-year-old man presented after one month of intermittent diplopia that resolved spontaneously.Neurological examination revealed diffuse hyperreflexia, bilateral Trömner sign, diplopia vocable after fatigability on the left gaze. Brain MRI revealed some abnormalities in the upper cervical spinal cord. Spinal cord MRI disclosed a longitudinally extensive T2-hyperintense lesion from CI to D1, with patchy gadolinium enhancement. Negative testing for aquaporin-4 and myelin oligodendrocyte glycoprotein antibodies by cell-based assay (fixed and live, respectively).Lumbar puncture showed mild pleocytosis (12 white blood cells/mm'), elevated proteins (70mg/dL; normal range, <40mg/dL). Chest CT revealed mediastinal lymphadenopathy. Transbronchial needle aspiration of a lymph node revealed non-caseating granulomatous inflammation, consistent with probable neuro-sarcoidosis. The patient was followed untreated for 3 months with stability of the spinal cord lesion on MRI. After he developed numbness in both hands and Lhermitte's phenomenon. Intravenous methylprednisolone was administered followed by slow tapering of oral, with prompt resolution of symptoms and marked improvement of the spinal cord abnormalities Conclusion: A marked clinical-MRI dissociation (i.e.,extensive MRI abnormalities accompanied by only mild clinical manifestations) is a big clue for diagnosis.
Neurology Letters