A 34-year-old man presented with ascending sensory changes in his legs. He reported a pins and needles sensation that started in his feet and ascended to his knees bilaterally. The patient presented to an outside hospital, where MRI scans revealed a T2 hyperintense lesion extending from C3 to C7 levels in the cervical spine. There was patchy gadolinium enhancement. MRI of the brain was unremarkable. His symptoms were thought to be secondary to transverse myelitis; he was treated with IV methylprednisolone, 1 g daily for 3 days, followed by a 5-day oral prednisone taper. The patient's symptoms resolved completely.Two weeks later, he again noticed a change of sensation in his feet. This pins and needles feeling ascended his legs and by 2 weeks later he was unable to feel his anus and genitals. He presented to our institution for evaluation. Neurologic examination was unremarkable except for altered sensation to light touch below the waist bilaterally. MRI of the cervical and thoracic spine showed a T2 hyperintense lesion from C2 to T2 with patchy gadolinium enhancement (figure A-C). Brain MRI was unremarkable. CSF analysis showed leukocytes 2 cells/mm 3 (100% lymphocytes), erythrocytes 2 cells/mm 3 , protein 76 mg/dL, glucose 65 mg/dL, negative bacterial, viral, and fungal cultures, and negative cytology, oligoclonal bands, and CSF neuromyelitis optica (NMO) immunoglobulin G (IgG). Serum tests were unremarkable including negative NMO IgG, HIV, rapid plasma reagin, antinuclear antibodies, angiotensin-converting enzyme, antineutrophil cytoplasmic antibodies, and serum protein electrophoresis; B 12 and erythrocyte sedimentation rate were normal. Admission chest roentgenogram showed hilar lymphadenopathy. CT scans of the chest, abdomen, and pelvis revealed nodules in the upper lobe of his right lung as well as bilateral hilar and mediastinal lymphadenopathy. Bronchoscopy with tissue biopsy demonstrated noncaseating granulomas consistent with sarcoidosis. He was treated with 5 days of IV methylprednisolone with lessening of his symptoms.The patient was discharged on oral prednisone 60 mg daily and azathioprine 150 mg daily. Repeat spine MRIs were performed every 3 months for the first year; these showed a progressive decrease in signal abnormality from C5 to C7, with subjective mild focal volume loss in this area and minimal patchy gadolinium enhancement. No new lesions appeared during this time.
Podcast
Practical ImplicationsConsider sarcoidosis in the differential diagnosis of long segment spinal cord lesions.