Nodular Leptomeningeal Enhancement in Neurosarcoidosis: Before and After Treatment

A 38-year-old man presented with 1 year of leg weakness. Examination showed proximal limb weakness, distal sensory loss, and diffuse hyperreflexia. Magnetic resonance imaging (MRI) of the brain and spinal cord showed multifocal nodular leptomeningeal enhancement (Figures 1 and and2).2). Cerebrospinal fluid analysis demonstrated lymphocytic pleocytosis, elevated protein, and undetectable glucose. Additional testing revealed panhypopituitarism and syndrome of inappropriate antidiuretic hormone secretion. Computed tomography of the chest showed a few slightly prominent mediastinal lymph nodes, which had mildly increased fluorodeoxyglucose activity on a subsequent positron emission tomography. Lymph node biopsy demonstrated noncaseating granulomas, establishing the diagnosis of sarcoidosis. Other granulomatous diseases, including tuberculosis and fungal infections, were excluded