Abstract Introduction Sarcoidosis is a multisystem granulomaous disease of unknown etiology that can involve any organ system. Its clinical manifestations are highly variable, ranging from asymptomatic disease to severe multi-organ involvement, making diagnosis and management challenging. Case Presentation A 63-year-old male presented after a new-onset, 3-minute seizure with right-sided weakness and right gaze deviation. A code stroke was activated. On arrival, he was hypertensive (202/99 mmHg), afebrile, and hypoxic (92%). During CT imaging, he experienced another self-limited seizure and was subsequently intubated for airway protection and admitted to the ICU. CT of the head, CT angiogram of the head and neck, and CT angiogram for aortic dissection revealed no acute intracranial or vascular abnormalities but showed innumerable miliary pulmonary nodules with upper lobe predominance and mediastinal lymphadenopathy. Laboratory evaluation was notable for hypercalcemia (13.4mg/dL), elevated BUN (28mg/dL) and creatinine (2.22mg/dL), low 25-dihydroxyvitamin D (19ng/mL), and elevated 1,25-dihydroxyvitamin D (154pg/mL). Infectious workup for mycobacteria, fungi, and viruses was negative. Lumbar puncture revealed elevated protein (86mg/dL) and angiotensin-converting enzyme (ACE) level (2.9U/L) without signs of infection. Continuous electroencephalogram showed diffuse encephalopathy, and MRIs of the brain and spine were unremarkable. Bronchioalveolar lavage, transbronchial biopsy, and endobronchial ultrasound transbronchial needle aspiration showed non-necrotizing granulomas consistent with sarcoidosis. The hospital course was complicated by sinus bradycardia and hypotension requiring brief vasopressor support, as well as a self-limited episode of atrial fibrillation with rapid ventricular response. Cardiac MRI suggested probable cardiac sarcoidosis. The patient was treated with intravenous methylprednisolone for suspected neurosarcoidosis, later tapered to prednisone 20 mg daily given poorly controlled hyperglycemia. Hydroxychloroquine 200 mg daily was started as a steroid sparing agent. He improved clinically and was discharged to a rehabilitation facility after a 2-week hospitalization. Discussion Seizure as the initial manifestation of sarcoidosis is rare. Although most patients with neurosarcoidosis showed MRI abnormalities, our patient had unremarkable neuroimaging with elevated cerebrospinal fluid ACE—a nonsensitive but relatively specific finding for neurosarcoidosis. This suggests a diagnostic role of CSF ACE when imaging is inconclusive. Additionally, the presence of miliary pulmonary pattern is an atypical radiographic presentation for sarcoidosis and can mimic infectious etiologies such as tuberculosis or fungal infections. Recognition of this rare presentation and confirmation with tissue biopsy are crucial to avoid misdiagnosis. This case highlights the variable manifestations of sarcoidosis and the importance of considering it in patients with unexplained seizures or miliary pulmonary findings, even without classic imaging features. This abstract is funded by: None
See et al. (Fri,) studied this question.