Applied Evidence

A stroke—or something else?

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References

The prognosis with sarcoidosis can vary widely. Case studies show that two-thirds of patients may have a nonrecurring illness. Among the remaining one-third, the disease course may be relapsing-remitting or progressive. When confronted with an acute neurologic event, consider recurrent sarcoidosis and coordinate care between specialists. Also, take steps to prevent complications related to prolonged steroid use.

TABLE 2
Treatment of neurosarcoidosis
3

Medication*Side effectsComments
MethylprednisoloneHyperglycemia
PrednisoneOsteoporosis, hyperglycemia, hypertension, diabetes, glaucoma, cataracts, psychosis, Cushing’s syndromeTaper as able. Concomitant use of cytotoxic agents may facilitate taper. Monitor glucose and give calcium/vitamin D prophylaxis
MethotrexateAnemia, neutropenia, liver damageWeekly dosing well tolerated. Give folic acid 1 mg/d. Monitor liver function tests periodically
CyclosporineRenal insufficiency, hypertension
AzathioprineAnemia, neutropenia, liver damage
CyclophosphamideCystitis, neutropeniaMonitor urine monthly for microscopic hematuria
HydroxychloroquineRetinopathy, hypoglycemia, ototoxicity, myopathy, cardiomyopathy, neuropathyRefer for eye exams every 3-6 months. May be useful to counteract hyperglycemic effect of steroids
InfliximabFever, headache, dizziness, flushing, abdominal pain, dyspepsia, myalgia, arthralgia, polyneuropathyScreen for tuberculosis before starting treatment. Contraindicated in patients with congestive heart failure
*For dosing details, consult a neurologist or rheumatologist

Improvement for our patient
Based on cerebrospinal fluid study results, a positive peripheral lymph node biopsy, and the exclusion of other diagnoses, we regarded the diagnosis of sarcoidosis as highly probable and initiated high-dose intravenous corticosteroids. Over several weeks, our patient gradually improved with physical therapy and was walking unassisted at the time of discharge from a hospital-based rehabilitation unit. Repeat MRI scans showed a reduction in the size of her intradural lesions, and we slowly tapered her steroids.

CORRESPONDENCE
Hillary R. Mount, MD, 2123 Auburn Avenue,#340, Cincinnati, OH 45219; hillary.mount@thechristhospital.com

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