The differential for a LETM lesion is very extensive, and to narrow the differential, the radiologist needs to pay careful attention to the clinical presentation (e.g. bilateral visual loss with hiccups suggesting NMO), additional clues on the imaging (as on this case), consider scanning the brain and orbits (to see characteristic lesions of MS, ADEM or NMO), and advise serologic examination (e.g. NMO IgG, autoimmune serology, ACE levels) and CSF analysis. Despite all this, the specific cause of a LETM can be very challenging to diagnose.
In this case, the chest findings on spinal MRI prompted further evaluation for sarcoidosis, which allowed for correct diagnosis and appropriate treatment. This illustrates the importance of looking at the whole scan when reporting spinal MRI.