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A1551 - A Common Disease Presenting Uncommonly as Stroke
Author Block: M. Sczepanski, B. D. Dalal; Beaumont Health, Royal Oak, MI, United States.
A thirty-nine-year-old female presented with acute onset of right-sided weakness and dysarthria. She was diagnosed with an acute ischemic stroke with NIHSS score of 5 but was not a candidate for tPA due to late presentation. Risk factors for atherosclerotic disease included smoking, family history, and being overweight. Initial computed tomography (CT) of the head was negative but cerebral arteriogram demonstrated occlusion of a branch of the left middle cerebral artery. To complicate the story further, chest X-ray showed multiple bilateral pulmonary masses and CT chest demonstrated multiple ground glass (GG) nodules/masses (3-5cm in size) with “vessel sign” and mediastinal adenopathy. Transbronchial fine needle aspiration (FNA) of the lymph nodes using endobronchial ultrasound (EBUS) guidance was performed along with transbronchial biopsy. All FNA/biopsies demonstrated non-necrotizing granulomas. With a strong family history of sarcoidosis in her mother and grandmother she was diagnosed with pulmonary and neuro-sarcoidosis. She was started on high-dosed steroids for neuro-sarcoidosis with a prolonged taper and discharged to inpatient rehabilitation. At discharge, she had improved lower extremity strength, aphasia, and dysarthria, but had persistent upper extremity weakness and remains wheelchair bound.
Sarcoidosis is a multisystem granulomatous disorder that most commonly affects the lungs. This case depicts unusual presentations of both neuro-sarcoidosis and pulmonary sarcoidosis. In regards to neuro-sarcoidosis, it is unusual for it to cause focal cerebral infarction. Additionally, her abnormal imaging with multiple GG masses with vessels going in to them is suggestive of hematogenous spread which is a less common type of progression than lymphatic spread.