Abstracts

Rationale: Common clinical presentations in neurosarcoidosis include cranial neuropathy, meningitis among others.  Cerebral granuloma as an initial presentation is relatively uncommon, occurring in about 5% of patients with neurosarcoidosis.  In addition, new-onset seizures is a less common presenting feature in neurosarcoidosis.We report a case of new-onset of seizures in a patient who demonstrated progressive cortical and subcortical nodular enhancement on serial MRI studies.  A primary neoplasm was suspected based on the clinical presentation and imaging findings.  However cerebral granuloma was confirmed by brain biopsy. Methods: Case report at George Washington University Hospital (GWUH) and review of literatures. Results: A 30-year-old previously healthy man was admitted to an outside hospital for new-onset of seizures.  His magnetic resonance imaging (MRI) study of his brain showed abnormal patchy nodular enhancement over the left temporal lobe.  He was treated with levetiracetam and then, he missed follow-up visits. He then presented to GWUH 4 months later.  A repeat MRI revealed significant progression of abnormal nodular enhancement as well as worsening edema, concerning for a primary cerebral neoplasm.  The electroencephalogram (EEG) studies confirmed that seizures originated from the left temporal region.  He had extensive cerebrospinal fluid (CSF) and serum studies, including viral, bacterial, fungal, autoimmune markers, vasculitis panel, and angiotensin-converting enzyme levels, which were all negative.  A brain biopsy was pursued which showed non-necrotizing and necrotizing granuloma.  The initial chest x-ray was negative.   Subsequent work up includes a Computed Tomography (CT) chest study which revealed bilateral hilar and subcarinal adenopathy and a right upper lobe pulmonary nodule.  A subsequent lesion/lung biopsy revealed multiple non-necrotizing granulomas that stained negative for fungal organisms and acid-fast bacilli.  Tuberculosis (TB) quantiferon gold test was negative.  He denies any pulmonary or systemic complaints such as fever, cough among others.  He remains asymptomatic and seizure free.  The clinical presentation, brain MRI, chest CT, CSF analysis and pathological findings are most consistent with neurosarcoidosis. Conclusions: New-onset of seizures can be caused by various underlying diseases.  The differentiation between solitary cerebral granuloma such as neurosarcoidosis and neoplasm could be challenging. Disease progression as seen in untreated cerebral granuloma can be similar to that of a primary neoplasm. Thorough systemic evaluation and potential brain biopsy may be needed to confirm the diagnosis. Funding: None