Thursday, March 15, 2012

Always Put This On Your Differential

A 40 year old woman presents with a right facial droop, initially thought to be Bell's palsy until she develops a left sided one subsequently. She presents to her primary care doctor who does a review of systems and finds polyuria as well as disturbances in thirst, sleep, appetite, and libido. Not much is done, and she is told to follow up in a few months. In the meantime, she has a partial seizure and returns to the hospital. A contrast-enhanced MRI shows nonspecific meningeal enhancement and multiple white matter lesions. A lumbar puncture shows a mononuclear cell pleocystosis and elevated total protein. Glucose is normal. A CT of the chest is obtained due to an abnormal routine chest X-ray and is shown below.

Challenge: What's your diagnosis?

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Reflex Hammer said...

Herpes zoster?

Craig Chen said...

that's definitely a possibility, esp given skin and neuro findings (esp seizure). i was trying to put together a case for neurosarcoid, but i like hsv as well.
Always Put This On Your Differential

This is neurologic sarcoidosis. The first image shows some cutaneous manifestations; the second image shows mediastinal lymphadenopathy. The symptoms describe neurologic manifestations of this systemic illness, including cranial mononeuropathy, neuroendocrine dysfunction, and granulomatous inflammation in a perivascular distribution. There are no specific findings on imaging or LP.

Sources: UpToDate; Wikipedia.