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MORNING REPORT

MORNING REPORT. Katie Doktor, PGY-2 July 13, 2010. Pt is a 30yoF. P/w new-onset R sided weakness, numbness and heaviness x2d. started in foot and gradually spread cephallicaly to ear only on lateral right side . PMHx. Sarcoidosis, dx’d ‘98 Depression Allergies: sulfa drugs

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MORNING REPORT

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  1. MORNING REPORT Katie Doktor, PGY-2 July 13, 2010

  2. Pt is a 30yoF • P/w new-onset R sided weakness, numbness and heaviness x2d • started in foot and gradually spread cephallicaly to ear • only on lateral right side

  3. PMHx • Sarcoidosis, dx’d ‘98 • Depression Allergies: sulfa drugs Social Hx: (+) tobacco, <1pk/d

  4. MRI Brain Persistent abnormality in the L hemisphere, just posterolateral to the 4th ventricle, which has markedly decreased since the prior study. Some persistent abnormality in the L cerebellar peduncle, which has markedly decreased since the prior study.

  5. Neurosarcoidosis • Occurs in less than 5% of pts w/sarcoid • Course: Can be monophasic, relapsing-remitting or progressive dz punctuated by episodic deteriorations • 50% of pts w/neurosarcoid p/w neuro Sx at time of initial sarcoidosis dx

  6. Neurosarcoidosis: common syndromes • Cranial nerve dysfunction • Parenchymal lesions • Encephalopathy • Meningeal disease • Peripheral neuropathy • Muscle weakness

  7. Neurosarcoidosis: differential Dx • Lyme’s disease, idiopathic Bell’s Palsy, optic neuropathy assoc’d w/MS, TB & carcinomatous or lympomatous meningitis • Astrocytoma or other primary metastatic brain tumors, MS • Meningitis caused by viral infxn (HIV), TB or syphilis. • Toxin exposure, metabolic abnl or inflamm d/o causing peripheral neuropathy

  8. Presentations

  9. Clinical Evaluation • Examine for evidence of extraneural disease • Ophthalmologic examination • Endoscopic nasal and sinus exam • CXR or CT chest • ACE may not be elevated in neurosarcoid • Neurodiagnosis tests • contrast-enhanced MRI • Lumbar puncture: elevated opening pressure, Tprotein up to 250, mononuclear cell pleocytosis, glucose low/nml, elevated IgG index, oligoclonal bands

  10. Neurosarcoidosis Tx • Corticosteroids • Dose/duration determined by dz severity and response to therapy • Alternatives • Azathioprine, methotrexate, mycophenolate mofetil, cyclophosphamide, cyclosporine, chloramibucil, infliximab, hydroxychloroquine, pentoxifylline, thalidomide • Other: Surgery, Radiation

  11. Last episode • LP- clear, colorless, Tprotein 110, WBC 3, RBC 183, alb 60.3, IgG 18.2, Glucose 50, IgG/alb 30.2, (+) oligoclonal bands • ACE: 37 (nml 9-67) • ACE in CSF: 7 (nml <15) • ANA positive • ESR 20

  12. This time • RF neg • C3 • C4 • ESR 13

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