Case 59: multiple CNS lesions and gait difficulty

posted: December 10, 2000

Resident: John Ratliff, MD
Attending: Bryan Payne, MD

CLINICAL PRESENTATION: 44 year old black man with progressive gait difficulty and balance problems after a fall off a bus few months prior to admission. The patient favors his left leg; he has a history of developmental delay and mental retardation as well as hypertension. No other significant past medical history.

EXAMINATION: On neurological exam he has a right peripheral facial paresis; failure to elevate the right palate; tongue protusion to the right; right pronator drift; 4/5 strength on the right side. 3+ deep tendon reflexes except ankle reflexes (1+); bilateral Babinski signs; broad based gait. Remainder of the neurological exam was normal.

Vital signs were normal. No other abnormalities noted in the general examination. Laboratory examinations normal.

DIAGNOSTIC STUDIES: An MRI scan of the brain with and without contrast was obtained first; the following select pict is shown below:

multiple enchancing nodules were seen in the base of the brain (red marker above), within the brainstem and subependymal in the supratentorial space

FURTHER DIAGNOSTIC STUDIES: CSF: protein 279; glucose 31 (blood glucose 120); RBC: 30; WBC: 150 (95% lymphocytes); no bacterial or fungal growth; CSF ACE: 2 (normal). Serum ACE: 3 (normal); CXR was normal; PPD and HIV tests were negative

A spinal survey was performed with MRI scan of the cervical, thoracic and lumbar spine. Select picts from the lumbar spine MRI scan (with contrast) is shown below:

Multiple enhancing lesions were seen throughout the spine- within the subarachnoid space predominately; including a lesion in the conus region as shown above (red marker)

STEPS TAKEN AT LSUHSC: Since the patient's symptoms were getting progressively worse, it was decided to biopsy the conus lesion to find the definite pathology. Select intraop picts are shown below:

The picts above show the lesion in the conus (white marker). The lower pict is a close-up of the lesion.

The conus lesion was excised, it was extra-axial in location.

PATHOLOGY: Neurosarcoid

Comments and Questions about this interesting case are welcomed. Please e-mail: dawast@lsuhsc.edu

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