Presentation
Hypoesthesia of changing localization, urinary complaints and an increasing tremor after epididymitis eight weeks ago.
Patient Data
The central canal of the spinal cord is dilated from C1 to TH12. There is a T2 hyperintense lesion in the conus medullaris. Additional C+ enhanced series recommended.
Normal signal of the bones. No spinal stenosis.
The contrast-enhanced spinal MRI shows a C+ enhancement of the central canal and the nerve roots. Furthermore, there is an enhancing lesion in the conus medullaris. Partially captured mediastinal lymphadenopathy.
Additional CT Thorax/Abdomen recommended because of the lymphadenopathy to rule out lymphoma or systemic inflammation.
The contrast-enhanced spinal MRI shows a C+ enhancement of the central canal (1) and the nerve roots (2). Furthermore, there is an enhancing lesion in the conus medullaris (3). Partially captured mediastinal lymphadenopathy (4).
Lymphadenopathy in the mediastinum, in the mesenteric root and the retroperitoneal space.
No pulmonary nodules. Partial dystelectasis of the upper left lobe.
Combining all the findings of the spinal MRI and the CT Thorax/Abdomen, either lymphoma or systemic sarcoidosis with central nervous involvement was suspected.
An additional C+ brain MRI was conducted to look for basal meningeal enhancement, which would be typical for neurosarcoidosis.
Normal cerebral MRI, no C+ enhancement of the basal meninges.
Case Discussion
A biopsy of the mediastinal lymph nodes was conducted. It showed lymphatic tissue with fragments of granulomas without necrosis but sclerosis due to sarcoidosis.
Bronchoalveolar lavage showed an elevated number of lymphocytes with a high T4/T8 quotient of 11 (normal 1,5-3,5) as part of lymphocytic alveolitis due to sarcoidosis with lung involvement.
CSF / liquor showed elevated lymphocytes in line with nonbacterial meningitis.
This case highlights an isolated spinal involvement in neurosarcoidosis with longitudinal myelitis. The epididymitis was probably the first clinical manifestation of the systemic sarcoidosis. The patient was treated with steroids, the symptoms decreased within a few days.