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Leptomeningeal neurosarcoidosis of the conus medullaris

Dowdy KED - MedPix

View Article: MedPix Image - MedPix Case

Affiliation: Walter Reed National Military Medical Center

ABSTRACT

Diagnosis: Leptomeningeal neurosarcoidosis of the conus medullaris

History: 54 yo LHD woman with a history of neurosarcoidosis who presents with progressively increasing weakness of her bilateral lower extremities L>R. Her neurologic symptoms began in 2009. She noticed that she was tripping and falling frequently, and it felt as if she was not lifting her legs up high enough. In March 2009, she had an MRI due to chronic lower back pain, at that time an intramedullary lesion at L1 and and extramedullary lesion at the conus medullaris were noted. Other symptoms included cough and shortness of breath. She was subsequently diagnosed with sarcoidosis by mediastinal lymph node biopsy in 2009. She was placed on oral prednisone for 7 months with minimal relief of symptoms. In 2011, she had a steroid infusion followed by methotrexate maintenance which she says helped her symptoms for several months. Her most recent infusion was in 2014, but she only had a 4 week improvement of symptoms. Over the past 2 months, the patient notes progressive weakness. Her left leg is more affected than her right leg. Pt began falling frequently and is no longer able to ambulate without assistance, she now uses a wheelchair. The patient also notes decreased sensation in both feet as well as decreased sensation in both lateral legs. The patient also has neuropathic pain in the legs for which she takes Neurontin. She reports occasional urge sensations in her bladder, but denies incontinence of bladder or bowel. At times she does experience urinary retention. Pt also endorses difficulty with writing, with her hands "more shaky" than usual over these past 2 months. She also has once weekly headaches, but denies any associated neurologic symptoms.

Findings: MRI of the lumbar spine with and without contrast: Comparison: MRI lumbar spine dated 5/14/2015 Findings: There are 5 non-rib bearing lumbar type vertebral bodies. The vertebral body heights and alignment are maintained. Disc desiccation is noted from L2 to S1, with partial disc height loss at L5-S1. Fatty degenerative endplate changes are again seen at L5-S1. The bone marrow signal is otherwise normal. No significant spinal canal or neural foraminal narrowing. The conus medullaris terminates in a normal location at the level of L2. There is increased enhancement and thickening of the nerve roots of the cauda equina with increased meningeal enhancement about the conus medullaris. Partially visualized sacroiliac joints are unremarkable. Paraspinal soft tissues are unremarkable. IMPRESSION: Interval worsening of diffuse leptomeningeal enhancement around the conus medullaris and cauda equina (thickened), compatible with progression of neurosarcoidosis.

Ddx: 1. Neurosarcoidosis 2. Tuberculous meningitis 3. Leptomenigeal carcinomatosis 4. Chronic Inflammatory Demyelinating Polyneuropathy 5. Lymphoma

Dxhow: Previous mediastinal lymph node biopsy. Negative PPD.

Exam: Neurologic Exam: Mental Status: Alert and oriented to person, place, time. Cranial Nerves: II: VFFTC, PERRL, OS: indistinct disc margins OD: indistinct disc margins III,IV,VI: EOMI, smooth pursuits, hypometric horizontal and vertical saccades. No primary or gaze-evoked nystagmus. V: MOMI, Sensation intact LT/PP V1/V2/V3. VII: Symmetric muscles of facial expression in upper/lower VIII: Hearing intact to conversation. IX,X: Symmetric volitional palate/uvula rise, no hypophonia, dysphonia, no dysarthria, no hoarseness. XI: 5/5 SCM and trapezius strength XII: Tongue midline on protrusion, no fasciculations or atrophy. Motor: normal bulk and tone. No fasciculations, mild tremor in hands L>R. No pronator drift. RUE: 5/5 deltoid, biceps, triceps, wrist flexion, wrist extension, finger flexion, interossei LUE: 5/5 deltoid, biceps, triceps, wrist flexion, wrist extension, finger flexion, interossei RLE: 3/5 hip flexion, hip ab/adduction, knee flexion/extension, 3/5 dorsiflexion, 4/5 plantarflexion LLE: 2/5 hip flexion, hip ab/adduction, knee extension, 3/5 knee flexion, dorsiflexion, plantarflexion Sensory: Intact and symmetric to light touch, temperature, and vibration in the upper extremities. Decreased light touch, temperature L>R bilateral feet and medial legs. Mildly decreased vibratory sensation bilateral lower extremities. Reflexes: -Right: Biceps 1/4, Triceps 1/4, BR 1/4, Patellar 0/4, Achilles 0/4, Plantar UP -Left: Biceps 2/4, Triceps 2/4, BR 2/4, Patellar 0/4, Achilles 0/4, Plantar UP Coordination: finger-nose-finger, finger tapping within normal limits with mild end-point tremor. Heel-shin normal. Gait: deferred due to weakness Labs unremarkable

No MeSH data available.


There is somewhat uniform thickening of virtually all of the visible nerve roots.
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MPX1111_synpic61323: There is somewhat uniform thickening of virtually all of the visible nerve roots.


Leptomeningeal neurosarcoidosis of the conus medullaris

Dowdy KED - MedPix

There is somewhat uniform thickening of virtually all of the visible nerve roots.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=MPX1111&req=5

MPX1111_synpic61323: There is somewhat uniform thickening of virtually all of the visible nerve roots.

View Article: MedPix Image - MedPix Case

Affiliation: Walter Reed National Military Medical Center

ABSTRACT

Diagnosis: Leptomeningeal neurosarcoidosis of the conus medullaris

History: 54 yo LHD woman with a history of neurosarcoidosis who presents with progressively increasing weakness of her bilateral lower extremities L>R. Her neurologic symptoms began in 2009. She noticed that she was tripping and falling frequently, and it felt as if she was not lifting her legs up high enough. In March 2009, she had an MRI due to chronic lower back pain, at that time an intramedullary lesion at L1 and and extramedullary lesion at the conus medullaris were noted. Other symptoms included cough and shortness of breath. She was subsequently diagnosed with sarcoidosis by mediastinal lymph node biopsy in 2009. She was placed on oral prednisone for 7 months with minimal relief of symptoms. In 2011, she had a steroid infusion followed by methotrexate maintenance which she says helped her symptoms for several months. Her most recent infusion was in 2014, but she only had a 4 week improvement of symptoms. Over the past 2 months, the patient notes progressive weakness. Her left leg is more affected than her right leg. Pt began falling frequently and is no longer able to ambulate without assistance, she now uses a wheelchair. The patient also notes decreased sensation in both feet as well as decreased sensation in both lateral legs. The patient also has neuropathic pain in the legs for which she takes Neurontin. She reports occasional urge sensations in her bladder, but denies incontinence of bladder or bowel. At times she does experience urinary retention. Pt also endorses difficulty with writing, with her hands "more shaky" than usual over these past 2 months. She also has once weekly headaches, but denies any associated neurologic symptoms.

Findings: MRI of the lumbar spine with and without contrast: Comparison: MRI lumbar spine dated 5/14/2015 Findings: There are 5 non-rib bearing lumbar type vertebral bodies. The vertebral body heights and alignment are maintained. Disc desiccation is noted from L2 to S1, with partial disc height loss at L5-S1. Fatty degenerative endplate changes are again seen at L5-S1. The bone marrow signal is otherwise normal. No significant spinal canal or neural foraminal narrowing. The conus medullaris terminates in a normal location at the level of L2. There is increased enhancement and thickening of the nerve roots of the cauda equina with increased meningeal enhancement about the conus medullaris. Partially visualized sacroiliac joints are unremarkable. Paraspinal soft tissues are unremarkable. IMPRESSION: Interval worsening of diffuse leptomeningeal enhancement around the conus medullaris and cauda equina (thickened), compatible with progression of neurosarcoidosis.

Ddx: 1. Neurosarcoidosis 2. Tuberculous meningitis 3. Leptomenigeal carcinomatosis 4. Chronic Inflammatory Demyelinating Polyneuropathy 5. Lymphoma

Dxhow: Previous mediastinal lymph node biopsy. Negative PPD.

Exam: Neurologic Exam: Mental Status: Alert and oriented to person, place, time. Cranial Nerves: II: VFFTC, PERRL, OS: indistinct disc margins OD: indistinct disc margins III,IV,VI: EOMI, smooth pursuits, hypometric horizontal and vertical saccades. No primary or gaze-evoked nystagmus. V: MOMI, Sensation intact LT/PP V1/V2/V3. VII: Symmetric muscles of facial expression in upper/lower VIII: Hearing intact to conversation. IX,X: Symmetric volitional palate/uvula rise, no hypophonia, dysphonia, no dysarthria, no hoarseness. XI: 5/5 SCM and trapezius strength XII: Tongue midline on protrusion, no fasciculations or atrophy. Motor: normal bulk and tone. No fasciculations, mild tremor in hands L>R. No pronator drift. RUE: 5/5 deltoid, biceps, triceps, wrist flexion, wrist extension, finger flexion, interossei LUE: 5/5 deltoid, biceps, triceps, wrist flexion, wrist extension, finger flexion, interossei RLE: 3/5 hip flexion, hip ab/adduction, knee flexion/extension, 3/5 dorsiflexion, 4/5 plantarflexion LLE: 2/5 hip flexion, hip ab/adduction, knee extension, 3/5 knee flexion, dorsiflexion, plantarflexion Sensory: Intact and symmetric to light touch, temperature, and vibration in the upper extremities. Decreased light touch, temperature L>R bilateral feet and medial legs. Mildly decreased vibratory sensation bilateral lower extremities. Reflexes: -Right: Biceps 1/4, Triceps 1/4, BR 1/4, Patellar 0/4, Achilles 0/4, Plantar UP -Left: Biceps 2/4, Triceps 2/4, BR 2/4, Patellar 0/4, Achilles 0/4, Plantar UP Coordination: finger-nose-finger, finger tapping within normal limits with mild end-point tremor. Heel-shin normal. Gait: deferred due to weakness Labs unremarkable

No MeSH data available.