| Description |
A 29-year-old African American woman presented with headaches, bilateral transient visual obscurations, blurred vision, numbness, and weakness of the lower extremities with myalgia and joint pains. She had an unplanned 12-pound weight loss over 2 months. A neurologist and internist diagnosed her with polymyalgia rheumatica, and placed her on prednisone 45 qod for this. Her past history included bronchitis. She had migraines, which led to a CT scan in 1986 and again in 1990, both reportedly normal. Her family history included two brothers who she said died of muscular dystrophy. The week before presentation, she was noted to have mild iritis OU. Her examination showed that she was 20/30 OD, 20/25 OS, Ishahira plates = 6.5/10 OD, 7/10 OD pupils 5/5 RRL, no APD. The motility and slit-lamp examination were normal. The field OD showed a nasal step, and an earlier inferior arcuate scotoma; the field OS had an early inferior arcuate defect. The fundi showed bilateral disk edema, OD>>OS. The MRI showed thickened and enhancing optic nerves, with prominent lacrimal glands, and enhancement of the seventh and eighth cranial nerves bilaterally . Her evaluation (on corticosteroids) was notable for ACE = 30 (normal), a chest x-ray demonstrating hilar adenopathy, and a gallium scan with increased hilar uptake bilaterally. The spinal tap showed glucose 54, protein 188, 0 RBC, 103 WBC (87% lymphs, 13% monos), oligoclonals (-) lgG 35-8 (<8.6), VDRL (-), and Lyme (-), a lacrimal biopsy was negative, she refused bronchoscopy, and the diagnosis was presumptive neurosarcoidosis. All signs and symptoms went away with 80 mg of prednisone followed by a slow taper. |
