Usefulness of 18F-FDG-PET/CT imaging in a patient with neurosarcoidosis

Jiménez-Bonilla, Julio F.; González-Gay, Miguel A.; Banzo, Ignacio

doi:10.1016/j.medcli.2018.02.024

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Jiménez-Bonilla, Miguel A. González-Gay, Ignacio Banzo" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Julio F." "apellidos" => "Jiménez-Bonilla" "email" => array:1 [ 0 => "jjimenez@humv.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Miguel A." 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Selected sagittal fused 18F-FDG PET/CT (B) image shows hypermetabolism in the spinal cord, especially at the upper and lower ends (arrows). Normal appearance of the spinal cord on MRI (C–E)." ] ] ] "textoCompleto" => "Neurosarcoidosis is a rare neuro-inflammatory disorder with protean manifestations which represents a diagnostic challenge. It can show different clinical presentation, from chronic meningitis to myelopathy.<a class="elsevierStyleCrossRef" href="#bib0020">1</a> Their identification in a patient is critical for applying an appropriate treatment in order to decrease the mortality and morbidity and to obtain lower relapse rates. Gadolinium-enhanced MRI is the preferred imaging modality for neurosarcoidosisWe report the case of a 30-year-old woman with an unremarkable past history presented to the hospital with a history of conjunctival hyperemia, photosensitivity and pain in the right eye of four weeks duration. She also complained of pain of both ankles, knees and lumbo-sacral region. She also noticed painful pretibial nodular lesions. A sarcoidosis was suspected. However, a chest radiograph did not show abnormalities. Symptoms worsened over the last two weeks prior to admission since she started to have vertigo and paresthesias in the tongue and in the left side of her face. On admission the physical examination disclosed a left-sided peripheral facial nerve palsy. Spinal and brain MRI were reported as being normal. A treatment with 30mg/day of prednisone was started. However, symptoms did not improve. In addition, and a bilateral uveitis with vitritis was also observed.An 18F-FDG PET/CT disclosed abnormal hypermetabolic uptake in the hilar and mediastinal lymph nodes, in both parotid glands and a diffuse uptake throughout the spinal cord, more intense at the upper and lower ends (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Taking into account the clinical data along with the 18F-FDG PET/CT findings a diagnosis of neurosarcoidosis was considered. Further studies included a lumbar puncture that showed abnormal cerebrospinal fluid consisting of raised protein level and lymphocytic pleocytosis and an increased CD4/CD8 ratio. A parotid gland biopsy confirmed the presence of non-caseating sarcoid granulomas. A treatment consisting of intravenous methyl-prednisolone pulses (500mg/day for three consecutive days) followed by oral prednisone 60mg/day for 3 weeks and then progressive tapering of the prednisone dose, methotrexate (10mg/week/subcutaneously), and intravenous anti-TNF-infliximab (5mg/kg at day 0, at week 2, week 6 and then every 8 weeks) was started. Following this treatment, the patients experienced a progressive improvement of symptoms. At present, 6 months after the diagnosis of sarcoidosis the patient is asymptomatic.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The present case is of interest because spinal and brain MRI were normal. However, an 18F-FDG PET/CT assessed the extent of the disease affecting the spinal cord. The diagnosis was confirmed by cerebrospinal fluid analysis. MRI and PET imaging discordance in neurosarcoidosis has been previously reported in some isolated reports.<a class="elsevierStyleCrossRef" href="#bib0025">2</a> Nevertheless, this relevant finding reinforces the useful role of 18F-FDG PET/CT in difficult cases, because it is able to show the metabolic abnormalities linked to neuroinflammation, specially in the absence of infiltrative spinal cord lesions, which are more suitable to be detected by MRI.<a class="elsevierStyleCrossRef" href="#bib0030">3</a>18F-FDG PET/CT offers an early metabolic window to investigate a potential neurosarcoidosis." 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Normal appearance of the spinal cord on MRI (C–E)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:3 [ 0 => array:3 [ "identificador" => "bib0020" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Many faces of neurosarcoidosis: from chronic meningitis to myelopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D. Fritz" 1 => "M. Voortman" 2 => "D. van de Beek" 3 => "M. Drent" 4 => "M.C. 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