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Abstract Details

A Rare Presentation of Biopsy-Proven Necrotizing Neurosarcoidosis in a Woman with Exposure to MDR-TB
Multiple Sclerosis
P13 - Poster Session 13 (5:30 PM-6:30 PM)
9-021
NA
Distinguishing between neurosarcoidosis and CNS mycobacterial infections can be exceedingly challenging. Diagnosis of CNS tuberculosis ideally consists of demonstration of organisms, yet this is difficult to achieve given the low sensitivity of AFB cultures. Establishing a diagnosis of neurosarcoidosis is also challenging because of the lack of diagnostic tests specific to this disease.
NA
A 56-year-old previously healthy woman presented with a 4 month history of daily headaches, double vision, gait instability, weight loss, and profound fatigue. She had a known exposure to an acquaintance with active multi-drug resistant pulmonary tuberculosis several months before. MRI of the brain and spine showed nodular leptomeningeal enhancement around the brainstem, cerebellum, cervical and thoracic spinal cord. CSF studies showed 189 WBC (94% lymphocytes), elevated protein (211), and low glucose (20). She was initially treated for CNS tuberculosis with antimicrobials and prednisone but her symptoms continued to worsen over several weeks. Leptomeningeal biopsy was performed showing occasional caseating granulomas but no organisms. Chest CT showed hilar lymphadenopathy and lymph node biopsy demonstrated caseating granulomas but no organisms. CSF metagenomic sequencing revealed no evidence of organisms. After 4 months of progressive decline despite treatment for tuberculosis, she was treated with infliximab for presumed necrotizing neurosarcoidosis which led to rapid improvement in her symptoms and imaging.
Distinguishing between neurosarcoidosis and CNS tuberculosis can be challenging. Additional layers of complexity in this case were the patient’s confirmed exposure to active TB, biopsy specimens with occasional caseating granulomas, and lack of response to prednisone. Although typically associated with non-caseating granulomas, sarcoidosis can present with caseating granulomas in its necrotizing form, as has been reported in several case reports. Neurosarcoidosis is typically corticosteroid-responsive but patients who deteriorate despite corticosteroids, as in this case, alternative therapies such as azathioprine, cyclophosphamide, methotrexate, rituximab, or infliximab are often used.
Authors/Disclosures
John Peters, MD (Yale-New Haven Hospital)
PRESENTER 		Dr. Peters has nothing to disclose.
Bogdan I. Patedakis Litvinov, MD (Yale Neurology) No disclosure on file
Nicholas Blondin, MD (Smilow Care Center - Trumbull) Dr. Blondin has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Novocure, Inc.. Dr. Blondin has received personal compensation in the range of $10,000-$49,999 for serving on a Speakers Bureau for Novocure, Inc..