Wednesday, August 15, 2012

One plus One equal (a complex) One

One morning about two months ago, I was reviewing my rounding list. Among the new patients there was a 62 yo W transferred from a regional hospital for possible stroke. It seemed another bread and butter case.

By the time I arrived in her room, the patient has been seen by the neurologist. He made the diagnosis - peripheral Bell's palsy (asymmetric smile, weak ipislateral forehead, but controlateral forehead was not weak). Indeed, the only obvious focal weakness was in her face.  So, I agreed with the neurologist and before concluding the encounter decided to ask the question that created me a lot of trouble in the past, What else is going on?

Well, she says, I have been diagnosed with uveitis. Uveitis and I are not were well accustomed. I am just an internist, so I have no plan to challenge the ophthalmologist's diagnosis, however at this point I think I can tell the ophthalmologist the etiology of the (anterior) uveitis. The next step sealed the diagnosis in my mind.

The excitement was running so high, without explaining the patient what I was going to do, I went for her neck. It did not take me too long to find plenty of enlarged cervical lymph nodes. Even the parotid gland was swollen. Then I excused for a minute and ran at the PACS station to take a another look at the MRI. Fortunately, the imaging was extended down to upper mediastinum. It had plenty of enlarged lymph nodes.

Heerfordt-Waldenstrom syndrome (facial nerve palsy, uveitis, parotid enlargement and fever) is one of the manifestations of sarcoidosis. She was referred to surgery for biopsy. Somehow the surgeon did not consider this case a priority and she had to stay in the hospital three more days. The ACE level came back before the biopsy was done. It was elevated 1.5 times the upper limit. At this point in time, I get my deserved free days.

The next day she started complaining of bilateral leg weakness. An MRI showed conus medullaris syndrome. Once the biopsy comes back with a diagnosis of sarcoidosis, she was started on steroids and two days later she felt much better.

It seems that she had neurosarcoidosis.

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