antithymocyte globulin, Cyclosporine, and Promacta.
mistaken for ITP and suspicion should be raised when steroids and IVIG are ineffective. Repeat bone biopsies should be performed in AATP to monitor treatment response and progression into aplastic anemia.
Discussion: AATP is a rare hematologic disorder that can evolve into aplastic anemia. It is still commonly
AN UNEXPECTED CASE OF NEUROSARCOIDOSIS Ian Tobal DO; Department of Medicine; Ochsner Medical Center; New Orleans, LA.
Introduction: Sarcoidosis is a multisystem inflammatory disorder characterized by non-caseating granuloma formation with subsequent fibrosis. 5-10% of patients with this condition have neurologic involvement. Case: A 58-year-old male status post C6-T1 laminoplasty was being treated for post-operative fevers considered secondary to a pulmonary embolism. He previously required neurosurgery for an intradural extramedullary lesion causing radiculopathy and lower extremity weakness. The partially resected mass was thought to be due to metastatic prostate cancer, but while hospitalized, the intra-operative pathology report returned showing non-caseating granulomas, indicative of neurosarcoid. While treatment was being decided, the patient began to experience worsening headaches, neck, and arm pain, and extremity weakness. Magnetic resonance imaging (MRI) at that time showed a 4 by 9 by 12 cm fluid collection at his surgical site, concerning for psuedomeningocele. Computed Tomography scans throughout this course also showed hydrocephalus developing. Steroid treatment was initiated. Days later, the patient began to complain of worsening pain and new-onset quadriplegia. Repeat MRI showed enlargement of the fluid collection, now 8 by 11 by
13 cm, and severe spinal cord compression. He was emergently taken to surgery for cerebrospinal fluid leak repair and drain placement. Later, after multiple complications, he was taken for ventriculoperitoneal shunt placement. His motor function improved but pain in the right upper extremity persisted. He was discharged to inpatient rehab on prednisone with plans to start a TNF inhibitor. Discussion: Sarcoidosis is an inflammatory condition that produces granulomas in various organs, often the lungs, lymph nodes, or joints, and presentation depends on the organs involved. Neurologic involvement is less common but can impact the central or peripheral nervous systems. In our case, the neurologic symptoms present were secondary to cord compression. In patients with cord involvement, hydrocephalus is a common complication. Once a patient is diagnosed with neurosarcoid, it is important to evaluate other systems for involvement, which is seen in a fourth of patients. ACE levels may be elevated, but it is not uncommon for normal levels in patients with only neural involvement. First-line treatment involves glucocorticoids with dosing and timeline dictated by disease activity. Immunomodulatory agents have been used but no evidence suggests they are superior to glucocorticoids.
BILATERAL CAVERNOUS SINUS THROMBOSIS AND SKULL BASE OSTEOMYELITIS IN A 52-YEAR-OLD FEMALE Yanming Yang DO; Department of Medicine, Ochsner Medical Center, New Orleans, LA.
Introduction: Both cavernous sinus thrombosis (CST) and skull base osteomyelitis (SBO) are exceedingly rare complications of infection and carry a high mortality rate. Case: A 52-year-old female with a history of intravenous heroin use presented for ophthalmology evaluation due to a bulging left eye. On presentation, she was afebrile and hemodynamically stable. Her physical exam was significant for bilateral cranial
nerve six (CNVI) palsy with periorbital edema and nuchal rigidity. Imaging obtained was significant for cavitary lesions in the lungs, bilateral CST, and hypophysitis. Her blood cultures returned methicillin sensitive staphlococcus aureus (MSSA). A trans- esophageal echo showed a Lambl’s excrescence although vegetation was not excluded. She was treated with cefazolin and heparin. Her symptoms improved, however she developed dysphagia and left sided tongue and uvula deviation consistent 28
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