Session: Poster session B

Recurring multiple eye muscle palsy as first sign of sarcoidosis

Introduction I will discuss the case of a 57 years old woman, who presented first in April 2014 with diplopia due to complete right sixth nerve palsy, which resolved spontaneously after 6 months. January 2017 she was diagnosed again with a sixth nerve palsy, this time on the left eye. May 2017 she presented with a complete palsy of the left third cranial nerve. Apart from the eye motility disorder, the neurological and ocular exam was completely normal. Medical history consisted of migraine and hypercholesterolemia for which she was taking a statin. No other cardiovascular risk factors could be withheld.  

Methods/Results Blood tests and lumbar puncture appeared normal. The first MRI showed a small incidental lesion in the right lateral ventricle for which follow-up was indicated and which remained unchanged. MRI, performed in May 2017, described a meningioma at the left cavernous sinus. This lesion could not explain the former cranial nerve palsies. CT thorax showed enlarged mediastinal and hilar lymph nodes and various nodules in the lung parenchyma as in the upper abdomen; an image suspicious of sarcoidosis. As a treatment of possible sarcoidosis, corticosteroids were started, with complete response within weeks. The assumed meningioma disappeared with this treatment, revealing it to be a sarcoid lesion. 

Conclusion In patients presenting with recidivating cranial nerve deficits, main differential diagnosis consists of multiple sclerosis, neuroborreliosis, increased intracranial pressure and neurosarcoidosis. In case of suspicion, brain MRI and CT Thorax should be obtained. Neurosarcoidosis has imaging properties very similar to other known diseases such as a meningioma and misdiagnosis occurs easily. Repeated brain imaging might be necessary. Accurate diagnosis is of great importance, since neurosurgical procedures can be avoided.