Frohman, Larry P. MD; Grigorian, Ruben MD; Bielory, Leonard MD
Sarcoidosis is a worldwide disease affecting all ethnic groups with an overall incidence of 6 to 10 per 100,000 (1). There appears to be a racial predilection for the development of the disease with a prevalence of sarcoidosis in the United States of 5 in 100,000 in whites and 40 in 100,000 in blacks (2,3). Women seem to be more commonly affected than men (2). The peak incidence is in the young adult population (1). The ophthalmic manifestations of sarcoidosis are reported to occur in 22% of patients sometime in its course (4). Neurologic involvement has usually been reported to occur in approximately 5 to 16% of patients with sarcoidosis (5). When it occurs, central nervous system (CNS) involvement may be an early manifestation of the disease, unmasking otherwise undetected systemic sarcoidosis (6). Various neurologic manifestations have been observed, including seizures, cognitive or psychic manifestations, hypothalamic and pituitary involvement, focal pseudotumors, and hydrocephalus (often associated with lymphocytic meningitis). Furthermore, cranial nerve palsies, particularly palsy of the facial nerve, are not uncommon. Inclusion of facial nerve palsies that are peripheral (e.g., secondary owing to sarcoidosis of the parotid gland, the so-called Heerfordt disease) may make the incidence of primary neurologic sarcoidosis in reported series seem misleadingly high.
Neuro-ophthalmic involvement is rare but often severe. Patients with neuro-ophthalmic sarcoidosis, unlike those with nonspecific neurologic signs such as headache or irritability, may present early in its course, as the symptoms of diplopia and visual loss are typically immediately noted by the patient and reported to their physician. When the neuro-ophthalmic symptom is isolated, it may be difficult to diagnose the underlying disease.
SUBJECTS AND METHODS
A retrospective review of all patients seen on the Neuro-Ophthalmology Service from 1989 to 1999 revealed 15 patients (11 women [73%] and four men), with an age range of 27 to 76 years, who presented with neuro-ophthalmic findings other than disease of the optic nerve, chiasm, and optic tract, which ultimately was diagnosed as owing to sarcoidosis. As experience evolved during the decade, the evaluation of suspected neuro-ophthalmic sarcoidosis became more standardized.
In most cases, the following laboratory evaluations were performed at presentation: chest radiograph (CXR), magnetic resonance imaging (MRI) of the brain (with fat-suppressed views of the optic nerves, with and without contrast), anergy panel, purified protein derivative (PPD), serum angiotensin-converting enzyme (ACE) level, 24-hour urine calcium, pulmonary function testing (PFT), lumbar puncture (LP), and gallium scan. Biopsy was performed in the 11 patients who permitted it.
Eleven women and four men with a mean age of 39.6 years (range, 27–76) were included in the study (Tables 1 and 2). Eight of 15 (53%) patients did not have known sarcoidosis at the time of neuro-ophthalmic presentation. Six of 15 (40%) patients had an abducens nerve palsy: three had isolated involvement; one had a combined lesion with a facial nerve palsy; one had combined oculomotor, trochlear, trigeminal, and abducens nerve palsies; and one had pseudo Tolosa–Hunt syndrome. Three of 15 (20%) patients had an oculomotor nerve palsy: one had an isolated pupil-sparing third nerve palsy, one is a patient described previously, and one patient had combined pupil-sparing oculomotor, trigeminal, and facial nerve palsies. Five of 15 (33%) patients had a facial nerve palsy: one had an isolated involvement, two patients with a combined involvement were described previously, one patient had it combined with fifth nerve palsy, and one had it combined with eighth nerve palsy. One patient had Parinaud syndrome. Two (13%) patients had unspecified diplopia. One (6.7%) patient had paracentral homonymous field defect with involvement of the occipital lobe.
Fourteen (93%) of the patients had pain (headache, n = 10 [71%]; ocular pain, n = 4 [29%]) at the time of neuro-ophthalmic presentation. Eleven (73%) patients also had intraocular or orbital manifestations of sarcoidosis: five of these had anterior uveitis; one patient had scleritis, and one had vitreitis. Two (13%) patients had an orbital mass, and one also had an enlarged lacrimal gland and conjunctivitis. Three (20%) patients had enlarged lacrimal gland with proptosis, one (7%) patient had pupillary synechia, and one (7%) patient had Koeppe nodules.
ILLUSTRATIVE CASE: PATIENT 1
A 30-year-old black woman was admitted to Neurology Service with a dull headache, bilateral blurred vision, and binocular diplopia that increased on right gaze, which progressed in severity over 1 week. Her medical history was significant for classic migraine. At presentation, her best visual acuity was 20/30 OU, examination revealed moderate abduction deficit OD, consistent with abducens paresis. The rest of her neurologic and ophthalmic examinations was normal. She was about to be discharged after a negative contrasted computed tomography (CT) scan of the head, with a working diagnosis of a first episode of ophthalmoplegic migraine; however, neuro-ophthalmic consultation believed that diagnosis to be unlikely. Because her pain was noted to be distributed in the first and second branches of the trigeminal nerve, a MRI scan of the brain, with contrast for attention to the cavernous sinus, was performed and demonstrated enhancement of the right cavernous sinus with a dural tail (Fig. 1).
Because of the suspicion of sarcoidosis, the patient's evaluation included a normal serum ACE level and LP, a positive PPD (the patient later remembered that she had received Bacille Calmette–Guérin), and a normal CXR. Gallium scan revealed enhancement in the right axilla (Fig. 2) and led to axillary node biopsy, which revealed diffuse nonnecrotizing and necrotizing granulomas consistent with sarcoidosis. The patient was placed on 60 mg of oral prednisone daily, and her symptoms rapidly resolved.
The combination of a sixth nerve palsy and the trigeminal distribution of her pain localized the process to the cavernous sinus; thus, directed neuroimaging was performed. Sarcoidosis is in the differential of painful cavernous sinus masses with a dural tail (in the pre-MRI days, many such cases were labeled as Tolosa–Hunt syndrome). Gallium scan was used to indicate where to perform a tissue biopsy to obtain a histologic diagnosis.
A CXR was performed on all patients: 10 (67%) patients had lesions on CXR consistent with sarcoidosis, six of which were histologically confirmed (Table 3). Of the five patients with a negative CXR, three permitted biopsy, and all had lesions consistent with sarcoidosis. Note that these three all had abnormal gallium scans, two of which had pulmonary uptake. The gallium scan was positive in 10 (71%) of the 14 patients tested.
Magnetic resonance imaging revealed lesions consistent with sarcoidosis in 13 (87%) cases, eight of which were confirmed by biopsy. The most common picture that we saw on the MRI scan was dural thickening with involvement of the cavernous sinus. In the three patients with a negative MRI, two had biopsy confirmation of sarcoidosis.
Only three of 14 (21%) patients tested showed anergy. The serum ACE level was elevated in only four (27%) of 15 cases. Although serum ACE level is often said to be a marker for pulmonary activity, note that of the 11 patients in whom the ACE was negative, nine had an abnormal CXR, four of whom also had pulmonary uptake on gallium scan. PFTs were negative in all cases. The spinal fluid was abnormal in 2 of the 12 patients who had a LP (both revealed pleocytosis).
Biopsies were consistent with sarcoidosis in 9 (82%) of 11 cases. Seven patients (47%) had biopsy-proven preexisting sarcoidosis. The two (13%) patients (patients 7 and 9) whose biopsy was negative had findings consistent with sarcoidosis on CXR and MRI (dural thickening under the temporal lobe, causing widening of the cavernous sinus and dural enhancement) and had an abnormal gallium scan; PPD was negative in both cases. Patients 4, 5, 6, and 12 refused biopsy. Patient 5 had an abnormal MRI scan suggesting sarcoidosis and an abnormal gallium scan, cutaneous anergy, an elevated serum ACE, and spinal fluid findings suggesting sarcoid (lymphomonocytic pleocytosis). Patient 6 had MRI and gallium scans suggestive of sarcoid as well as cutaneous anergy and an elevated serum ACE level. Patient 12 had an abnormal CXR and gallium scan, and patient 4 had CXR, gallium scan, and MRI suggestive of sarcoid. The two (13%) remaining patients (patients 1 and 3) had no history of sarcoidosis and ultimately had positive biopsies. Sarcoid was suggested in patient 1 by a MRI scan, an abnormal gallium scan, and anergy (illustrative case). In patient 3, sarcoidosis was suggested by consistent MRI and gallium scan, an elevated ACE level, and orbital and lacrimal masses, with the latter yielding a positive biopsy.
The initial therapy of neurosarcoidosis is systemic corticosteroids (Table 4). All our patients received oral prednisone (initial dose, 1–1.5 mg/kg daily). The dose was tapered when the symptoms resolved (or in one case, withdrawn when there was no improvement). One patient developed adverse effects at levels of corticosteroids required to control his disease process. These were intolerable weight gain and steroid-induced diabetes and necessitated the addition of cyclosporine as a steroid-sparing agent. One patient did not respond to prednisone therapy and was changed to cyclosporine.
Sarcoidosis is a systemic disease of unknown cause that commonly involves the eye and infrequently involves the CNS. The etiology of sarcoidosis is unknown. Evidence suggests that sarcoidosis occurs as the result of an imbalance in T-cell location and function, causing an exaggerated cellular immune response and an increased T-helper/inducer response (1).
There are several candidates for the inciting antigen; recent evidence points to infectious agents, especially Mycobacterium species (5). Sarcoid granulomas are typically noncaseating and consist of epithelioid cells that are surrounded by a border of mononuclear cells, usually lymphocytes (7). Organ dysfunction seems to result from distortion of the normal architecture of the affected tissue by granulomas and subsequent fibrosis rather than by production of mediators that lead to damage (1). Neurologic sarcoidosis represents an uncommon but serious manifestation of sarcoidosis (8). When neurologic involvement occurs in the course of known sarcoidosis, the diagnosis of neurosarcoidosis is typically suspected. However, the neurologic involvement may occur long before the onset of systemic symptoms, and oftentimes sarcoid is not included in the differential diagnosis. Involvement of the nervous system poses a difficult diagnostic problem for the clinician unmasking previously occult sarcoidosis (9). MRI is the investigation of choice in detecting parenchymal changes in the brain of patients with sarcoidosis (10). It has been reported that MRI has high sensitivity and specificity for evaluation of neurosarcoidosis (9–11). Involvement of the nervous system can range from peripheral or cranial neuropathy to CNS disease (12,13).
Lower et al. (8) identified patients with neurologic manifestations of sarcoidosis. At their institution, 71 (13%) of 554 patients with sarcoidosis (definite or probable status) had evidence of nervous system involvement. Seventh (facial) cranial nerve palsy was the most common manifestation identified in 39 (55%) patients, including 24 (34%) patients with facial nerve palsy as the only manifestation of neurologic sarcoidosis. Facial nerve palsy is the most frequent neurologic presentation of sarcoidosis (14). Oculomotor, trochlear, and abducens nerve palsies were identified in only eight (11%) of their cases. Optic neuropathy (excluded in our current series) was seen in seven (10%) of the patients of Lower et al. Other peripheral or cranial nerve involvement and CNS manifestations were observed in 16 (22%) patients.
Recio et al. (Clinical and radiological analysis of neurosarcoidosis, Paper presented at the 1997 North American Neuro-Ophthalmology Society Meeting, Keystone, CO, February 1997) reported their series of 520 patients with biopsy-proven sarcoidosis. Thirty-two (6.3%) had neurologic symptoms; 13 (41%) had their neurologic symptoms associated with systemic signs, the most common of which were weakness (n = 14), facial paresis (n = 7), headache (n = 8), seizures (n = 8), and visual loss (n = 7).
In our series, 13 of 15 (87%) patients had symptoms or findings suggestive of one of the CNS palsies, except one patient who developed only homonymous paracentral field defect (involvement of the occipital lobe on MRI) and one with Parinaud syndrome (Table 1). MRI revealed lesions consistent with sarcoidosis in 13 (87%) patients (Table 3). Five (33%) patients had evidence of seventh nerve involvement, four of whom had characteristic changes for sarcoidosis on MRI.
Neuro-ophthalmic manifestations of sarcoidosis are rare and include optic neuritis, parachiasmal involvement, and lesions of the optic tract (anterior visual pathway disease has been excluded in this article and will be the subject of a separate report), and disorders of ocular motility. They can be the presenting sign of sarcoidosis. In eight (53%) of our cases, it was a neuro-ophthalmic finding that led to investigation and diagnosis of the systemic disease. In the other seven (47%) of our patients, neuro-ophthalmic signs developed after the systemic diagnosis was made.
Physicians need be aware that sarcoidosis can present initially with a neurologic–ophthalmic manifestation. MRI of the brain or orbits is the best choice for initial imaging study. If sarcoidosis is suggested by the MRI findings, which may include lacrimal gland, meningeal or hypothalamic enhancement, and pituitary stalk involvement, then a focused diagnostic evaluation is indicated. We recommend that CXR, anergy panel, PPD, ACE, gallium scan, and spinal tap be performed, although LP is more frequently abnormal in cases of anterior visual pathway disease than in this series. PFTs and 24-hour urine calcium were not helpful in identifying cases of sarcoidosis; it appears that they are useful in cases of anterior visual pathway disease (Frohman, Unpublished data).
Computed tomography scan of the chest may prove to be a useful adjunct. Kosmorsky et al. (15) presented a series of elderly white women with bilateral chronic uveitis. All had a negative CXR. Chest CT showed mediastinal lymphadenopathy in all cases, which led to ultimate histologic confirmation of sarcoidosis, although it may identify the same cases that gallium scan identifies.
Systemic corticosteroids are the mainstay of therapy and should be given to all cases with acute neurologic involvement. Other immunomodulatory agents such as cyclosporine may be effective in refractory cases or when the patient cannot tolerate the dose of corticosteroids required to control the disease process. Because cyclosporine has specific inhibitory effects on monocyte and T-cell activation via decreased interleukin-1 and interleukin-2, blocks B-cell activation, and improves hyperglycemic control, it should be an effective therapeutic agent for refractory sarcoidosis. Low-dose cyclosporine is a safe and effective therapeutic alternative in granulomatous disease (16). Others used azathioprine, cyclophosphamide, chlorambucil, and methotrexate as alternative treatment (17). In our series, neuro-ophthalmic symptoms, when treated acutely, generally responded well to therapy.
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