A 52-year-old African-American woman was diagnosed with pulmonary sarcoidosis 15 years ago and remained asymptomatic from her lung disease. She was then diagnosed with neurosarcoidosis 5 years ago after she developed visual changes and headache and MR imaging demonstrated optic nerve atrophy and enhancing meningeal lesions. Treatment included methotrexate, prednisone, mycophenolate, and cyclophosphamide, however, over a year, the meningeal lesions grew and bifrontal vasogenic edema developed. Her symptoms progressed to include progressive cognitive decline, dizziness, and generalized weakness and she presented to an outside hospital where she was treated with two weeks of high dose dexamethasone for presumed progression of neurosarcoidosis. Her symptoms persisted and she was transferred to our hospital.
Given the refractory nature of her condition, the diagnosis of neurosarcoidosis was re-evaluated. A repeat brain MRI showed diffuse heterogeneously enhancing, multinodular dural thickening along the bilateral frontal and right temporal convexities. CSF analysis showed glucose of 196, elevated protein of 87, 1 nucleated cell and ACE of 1.3. A craniotomy was performed for open biopsy and epidural and subdural purulence was encountered. Histologic examination of the dural lesions revealed fungus balls and fungal cultures grew Aspergillus spp. Voriconazole was initiated and the patient had immediate symptomatic improvement.