Endocrine Abstracts

Sarcoidosis is a granulomatous multi-systemdisorder of unknown ethology. It has a higher prevalence in Northern Europe and the UK. Neurosarcoidosis is a relatively less common, but serious complication of sarcoidosis. CASE: A 48 year old man presented to the hospital with intermittent fever, and neck pain and stiffness, of six weeksduration. This was associated with excessive tiredness, loss of libido, decreased appetite, and unintentional weight loss of two stone over a period of three months. Past history of firm painless cervical lymphadenopathy three years prior for which he wasreferred to haematology. CT of thorax, abdomen and pelvis at the time showed bilateral hilar, axillary and cervicallymphadenopathy. He was diagnosed with sarcoidosis as lymph node biopsy showed epithelioid granulomas, elevated serum angiotensin converting enzyme (ACE) levels, and negative cultures and serology. Since no major organs were involved, he was not commenced on any treatment. On examination this time, hewas hypotensive, with palpablebilateral, firm, non-tender cervical lymph nodes, and nuchalrigidity. There were no other significant clinical findings on examination. On investigation, routine blood tests showed he was anemic with leukopenia (lymphopenia). Blood culture was negative. He underwent a CT thorax, abdomen and pelvis to rule out malignancy. It showed similar, but more extensive lymph node involvement than before. He also had a MRI head with contrast due to associated visual disturbances, which showed multifocal leptomeningeal disease involving cranial nerves, ventricular system and pituitary stalk. CSF examination showed elevated protein (1.23 g/l) and lymphocytes (15), but was sterile, with normal ACE levels. Pituitary function tests were suggestive of hypopituitarism, involving gonadal and thyroid axes, which explained his presenting complaints. His paired osmolalities and electrolytes levels were normal suggesting no evidence of diabetes insipidus. Cervical lymph node biopsy reported presence of non-necrotising epithelioid granulomas. He was commenced on high dose Prednisolone initially, followed by Azathioprine, for neurosarcoidosis alongside hormone replacement, with which he improved. Subsequent MRI scans showed resolution of the lesions in the pituitary and other involved structures, along with improvement in symptoms.

Conclusion: Neurosarcoidosis is an uncommon presentation of sarcoidosis and it may often be sub-clinical. Since it can manifest if various ways, it can be a challenge to diagnose it early. Although it can affect any part of the nervous system, the pituitary gland, hypothalamus and cranial nerves are most commonly involved. Therefore, patients with sarcoidosis, especially those with inactive disease and vague systemic symptoms, should be evaluated for related hypopituitarism.