Andrea Tufano, BS*, Hofstra Northwell School of Medicine, Manhasset, NY;Ryan Sugarman, MD, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY;Joshua C Berkowitz, MD, Hofstra Northwell School of Medicine, New Hyde Park, NY and Syed E. Ahmad, MD, Hofstra Northwell School of Medicine, North Shore University Hospital, Manhasset, NY

Meeting: Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev.

Abstract number: 761

Categories: Adult, Clinical Vignette Abstracts

Keywords: , ,

Case Presentation: A 59-year-old woman with a history of ductal carcinoma in situ status post mastectomy presented with dizziness exacerbated by change of head position. Patient endorsed a history of intermittent dizziness in the past few weeks, which caused her to fall on her right hip on three occasions. Hip radiograph showed no evidence of fracture, however, she complained of pain associated with new numbness and paresthesias in the ipsilateral extremity. There was no loss of consciousness or head trauma. Physical exam was significant for positive Dix Hallpike maneuver. MRI of brain and spine revealed multiple areas of abnormal enhancement in the thoracic spine with associated edema, interpreted as most likely carcinomatosis and metastatic disease. Subsequent CT chest showed extensive mediastinal and hilar lymphadenopathy suspicious for metastatic lesions versus lymphoma. To further evaluate these findings, endobronchial ultrasound with transbronchial lymph node biopsy was performed. Pathology was consistent with spinal cord neurosarcoidosis. The patient was started on corticosteroid therapy, and repeat MRI spine one month after treatment initiation showed improvement of leptomeningeal disease. She has not had further episodes of dizziness or falls. 

Discussion: Sarcoidosis is a multisystem disorder characterized by non-caseating granulomatous inflammation. Neurologic complications occur in approximately 5% of patients, however sarcoidosis with spinal cord involvement is very rare, affecting less than 1% of patients. Here we present a patient with a history of malignancy found to have leptomeningeal enhancements on spinal imaging. Although the clinical picture was initially consistent with cancer, the patient was ultimately found to have biopsy-proven sarcoidosis. In this case, there were several reasons to not immediately consider spinal cord sarcoidosis. Given her history of DCIS, leptomeningeal enhancements were immediately suspicious for malignancy. Secondly, although the patient endorsed leg weakness, the patient’s fall history suggested trauma as a reasonable explanation. In fact, the reason for her falls was initially the more salient question, and prompted the brain MRI. Spinal imaging was added with the goal of simultaneously evaluating her paresthesias. For these reasons, the diagnosis of spinal cord neurosarcoidosis initially seemed improbable.

Conclusions: Dizziness associated with fall is a common problem encountered by the hospitalist. Such patients should be evaluated for a broad range of differential diagnoses including neurosarcoidosis. Specifically, spinal cord sarcoidosis should be considered in the differential for leptomeningeal enhancements, especially in a patient presenting with paresthesias or weakness, with lymphadenopathy on imaging. Given the highly invasive nature of neural tissue biopsy, an evaluation for extraneural sarcoidosis should be performed (i.e. lymph node biopsy). Prompt treatment with corticosteroids is important to limit long-term morbidity from this disease.

To cite this abstract:

Tufano, A; Sugarman, R; Berkowitz, JC; Ahmad, SE . WHEN CANCER ISN’T THE ANSWER: NEUROSARCOIDOSIS MASQUERADING AS MALIGNANCY IN A PATIENT WITH HISTORY OF BREAST CANCER. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 761. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/when-cancer-isnt-the-answer-neurosarcoidosis-masquerading-as-malignancy-in-a-patient-with-history-of-breast-cancer/. Accessed February 21, 2020.

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