A 53-year-old man suffers from unsteady gait, urinary incontinence and confusion. Hydrocephalus is quickly suspected. However, doctors can make an accurate diagnosis in just a few detours.
A 53-year-old woman is hospitalized with unsteady gait, urinary incontinence, and confusion. Her medical history is known to include hypertension, which is treated with medication. The woman noticed the symptoms more than a year ago. Then they were accompanied by headaches and blurred vision, which were initially treated as migraines.
Look for clues in the liquor
A recent MRI showed dilated ventricles, so the patient was admitted with suspected hydrocephalus.
The doctors first take routine laboratory values, but there are no abnormalities except for lymphopenia, which was already known. In order to further investigate the possible cause of the hydrocephalus, doctors are now removing the lye. Laboratory medical examination shows an elevated leukocyte count of 60 cells/µL and an elevated protein of 1.04 g/L. In addition, the glucose value is low, 1.6 mmol/l. In order to further clarify these findings, the doctors also require flow cytometry of the cerebrospinal fluid, which will confirm lymphocytosis with predominantly T cells – no atypical lymphoid infiltrate is phenotypically demonstrated.
But where does this lymphocytosis come from? To answer this question, doctors will have X-rays and CT scans done. Although this is extensive lymphadenopathy, the actual cause has still not been found.
So doctors take a closer look at the woman’s brain again using an MRI with a contrast agent.
On second glance
In fact, they show enrichment in the occipital lobe and in the tectal plate.
Further biopsy of the right inguinal lymph node revealed granulomatous lymphadenitis.
The patient is then extensively tested for infections and autoimmune diseases – but all tests are negative. However, the successful exclusion of these diseases allows doctors to arrive at another diagnosis: It is most likely neurosarcoidosis.
The patient is then treated with 1 mg of methylprednisolone intravenously for 3 days followed by 60 mg of oral prednisolone daily. After 5 days of steroid treatment, her cognitive abilities and walking unsteadiness gradually improve. It is then released and the dose of prednisolone is slowly reduced over time. Azathioprine treatment is also started four weeks after discharge.
Source of text and images: Pandey et al. / BMJ Case Reports
Title: Pawel Czerwinski / Unsplash