Transverse myelitis as an initial presentation of sarcoidosis

A patient presented with progressive lower limb weakness, sensory disturbance and bladder and bowel dysfunction, initially raising concern for cauda equina syndrome. Lumbar MRI excluded compressive pathology, and further imaging revealed a long-segment thoracic cord T2 hyperintensity suggestive of transverse myelitis (TM). Cerebrospinal fluid analysis supported an inflammatory cause. CT imaging identified mediastinal and supraclavicular lymphadenopathy, and lymph node biopsy confirmed non-necrotising granulomatous lymphadenitis, consistent with sarcoidosis. The diagnosis was TM secondary to neurosarcoidosis. High-dose corticosteroids and physiotherapy were initiated, followed by infliximab as a steroid-sparing agent. Follow-up demonstrated radiological improvement and functional gains, though mild deficits persisted. This case highlights the importance of rapidly distinguishing between compressive and non-compressive spinal cord syndromes, the need for systematic investigation of inflammatory myelopathies, and the role of multidisciplinary management in neurosarcoidosis.