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Abstract Details

Identification of Brain and Spinal Cord Abscesses in a Patient with Recently Diagnosed Neurosarcoidosis
Autoimmune Neurology
P6 - Poster Session 6 (5:30 PM-6:30 PM)

Sarcoidosis is a multisystem inflammatory disorder characterized by granuloma formation, with 5% of patients developing neurosarcoidosis treated with immunosuppressants. We describe a case of a 38-year-old African-American male who presented to the hospital following a motor vehicle trauma. Further history indicated progressive cognitive decline over eight months.

MRI showed diffuse, nodular leptomeningeal enhancement of the brain and spine, consistent with neurosarcoidosis. CT chest showed hilar lymphadenopathy. Lumbar puncture results showed elevated cerebrospinal fluid (CSF) Angiotensin-converting enzyme (ACE). Lung biopsy revealed non-necrotizing granulomas, consistent with sarcoidosis and he was started on an aggressive outpatient immunosuppression regimen of high dose oral prednisone and azathioprine.

He was admitted to the hospital one month later with intractable vomiting. He was given intravenous methylprednisolone for suspected progression of neurosarcoidosis but developed rapidly progressive quadriplegia and respiratory failure. MRI brain showed a new 16 mm ovoid lesion in the right basal ganglia with peripheral enhancement and restricted diffusion. MRI cervical spine showed a similar enhancing intramedullary lesion with restricted diffusion from C1 to C4.

A brain biopsy was performed on the right basal ganglia lesion resulting in purulent drainage that later grew Streptococcus anginosus. He also underwent a laminectomy and surgical wash out of the cervical spine abscess. Corticosteroids were tapered and the patient gradually improved with antibiotics, regaining partial motor and sensory function in all four extremities.

We describe a unique case of rapidly progressive quadriplegia in a patient with recently diagnosed neurosarcoidosis who was found to have biopsy-proven bacterial abscesses in the brain and cervical spine.
This case provides a unique challenge for the diagnosis of intracranial and intramedullary abscesses in patients with neurosarcoidosis. Abscess should be considered in the differential diagnosis of patients with neurosarcoidosis presenting with acutely worsening neurological symptoms and new intraparenchymal lesions with restricted diffusion on MRI.
Karishma A. Popli, MD, MBE (Johns Hopkins University)
Dr. Popli has nothing to disclose.
Ryan T. Lamb, MD Mr. Lamb has nothing to disclose.
Yasir Al-Khalili, MD, FAAN (Georgetown University) Dr. Al-Khalili has nothing to disclose.
Neel Dixit, MD (VCU) Dr. Dixit has nothing to disclose.