CHEST Guidelines-Spelunking-Meckel-Cave

Spelunking-Meckel-Cave_chest

Pdf Summary

A 31-year-old woman presented with loss of taste and smell, frontal headache, facial numbness, photophobia, and horizontal diplopia, exacerbated by distant vision. Her medical history included ankylosing spondylitis, treated with etanercept. On examination, notable findings were decreased sensation in areas served by the trigeminal nerve and signs indicating right inferior oblique muscle paresis. Basic labs and imaging of the brain suggested bilateral trigeminal nerve issues. Elevated cerebrospinal fluid (CSF) protein levels and lymphocyte predominance were noted, but without malignancy. A chest CT revealed lymph node abnormalities without interstitial findings.<br /><br />The patient was diagnosed with pulmonary sarcoidosis with probable neurosarcoidosis. Sarcoidosis is a multisystem disease that sometimes involves the nervous system. Neurosarcoidosis, a rare condition, manifests through cranial neuropathies and requires distinct treatments including high-dose steroids. There may also be an association with TNF-a antagonist therapy, as used in treating ankylosing spondylitis. Etanercept, unlike infliximab or adalimumab, has less efficacy in treating sarcoidosis and is potentially related to increasing granulomatous diseases. <br /><br />This case possibly represents etanercept-associated sarcoidosis. High-dose IV methylprednisolone was administered, followed by oral prednisone. Symptoms improved, but side effects from steroid treatment occurred. The patient's treatment includes a steroid taper and azathioprine. Key clinical insights suggest neurosarcoidosis should be considered when patients present with cranial neuropathies and TNF-a antagonists may contribute to sarcoidosis-like conditions. Treatment involves discontinuing such medications and using high-dose steroids.

Keywords

neurosarcoidosis

ankylosing spondylitis

etanercept

cranial neuropathies

TNF-a antagonist

steroids

trigeminal nerve

pulmonary sarcoidosis

granulomatous diseases

azathioprine