Requested Labs & Studies

• ESR = 75 mm/hr
• CRP = 3.5 mg/dl (normal < 0.5 mg/dl)
• ACE = 62
• CBC wnl
• ALT = 79 U/L
• AST = 74 U/L
• Alkaline Phosphatase = 189 U/L

Discussion

Although more common in African Americans, sarcoidosis can be found in Caucasians. In Iowa, we see numerous new cases yearly, and sarcoid must be on the differential of unilateral or bilateral vision loss associated with systemic manifestations, e.g. weight loss, fatigue, breathing problems, fevers, and dry eyes. Sarcoid can manifest in the lacrimal and parotid glands; thus, patients may complain of severe dry eyes or dry mouth. The above MRI imaging studies denote nodular inflammation of both optic nerves (right greater than left optic nerve).

An elevated ACE and liver enzymes in this patient suggest lung and liver disease. The chest x-ray showed a single, large nodule in the left upper lobe. Without a CT scan and biopsy, the differential diagnosis should include lung tumor at this point. A CT scan was performed which showed perihilar lymphadenopathy as well as the large left upper lobe nodule. Bronchoscopy was performed, and aspirate showed numerous non-necrotizing granulomas, which supports the diagnosis of sarcoidosis. Sarcoidosis can be associated with uveitis or retinal lesions; however, the absence of uveitis or retinal disease does not rule-out sarcoid.

Sarcoid is a multi-systemic disease that may affect the: skin, brain, eyes, lungs, spleen, thyroid, and liver. It is a vision threatening and deadly disease, and sarcoid is responsive to aggressive immunosuppression therapy with high dose steroids.

This patient was admitted to the neurology service for neuro-sarcoidosis and started on IV steroids. Her vision in the right eye did not improve, but the left eye improved from 20/40 to 20/20 in two days. Her visual field also improved:

Diagnosis: Sarcoidosis

Differential Diagnoses

• Atypical optic neuritis
• lymphoma
• paraneoplastic syndrome
• vasculitis