Neurosarcoidosis: Granulomatous Disease Presenting with Confusion and Gait Disturbance

Introduction: Sarcoidosis is a multisystem disorder characterized by noncaseating granulomas that frequently presents with pulmonary infiltrates, hilar lymphadenopathy, and ocular and skin lesions. Sarcoidosis affects about 20 per 100,000 individuals in the US with a higher prevalence among African Americans than in Caucasians.1 The average age of presentation ranges from 33 to 41 years.1 Less than 10% of people with sarcoidosis have CNS involvement, with cranial neuropathy, aseptic meningitis, hydrocephalus, seizures, psychiatric symptoms, and cerebral lesions with endocrine manifestations included among the possible manifestations.2 This case report describes a woman with neurosarcoidosis presenting with confusion and gait disturbances. Case Presentation: A 59-year-old woman with a past medical history of hypertension and diabetes presented with one month of progressive confusion, lower extremity weakness, and gait instability. Prior to admission, she was treated at an outside hospital for presumed aseptic meningitis without improvement. The following diagnoses were present on admission: acute kidney injury with a creatinine of 2.1 mg/dL, a FeNa of 3.3%, and hypercalcemia to 14.5 mg/ dL. The physical exam was only notable for a persistent low grade fever averaging 100.3°F. She had no other symptoms. During the course of her admission, she developed polyuria which prompted a discussion of possible diabetes insipidus. A brain MRI without contrast ordered to evaluate this possibility showed mild dilatation of the lateral and third ventricles, suggestive of non-obstructive hydrocephalus. A subsequent lumbar puncture revealed an elevated opening pressure and elevated protein of 64 mg/dL. In the CSF, the ACE level was normal at 8U/L, the glucose level was 51 mg/dL, and oligoclonal bands were seen. No other cytological or pathological findings were noted