A History of Sarcoidosis and a New Brain Lesion

A 59-year-old man with long-standing hypertension sought a second opinion for a left-sided posterior headache and aphasia of approximately 1 week’s duration. Eight months before neurologic symptom presentation, he was febrile with night sweats, weight loss, arthralgias, dyspnea, and wheezing. Bronchoscopy and hilar lymph node biopsy showed noncaseating granulomatous inflammation consistent with pulmonary sarcoidosis. Remotely, as a teenager, given exposure to a family member with active pulmonary tuberculosis infection, he had a purified protein derivative skin test, which was positive; he received 6 months of isoniazid treatment. On examination, he was aphasic but had an otherwise normal neurologic examination. Brain magnetic resonance image performed at hospital admission (1 week after symptom onset) showed extensive T2 signal abnormality in the left temporal neocortex, with vasogenic edema, and abnormal gyriform gadolinium enhancement. There was no restricted diffusion in the left temporal lobe on diffusion-weighted imaging, but an apparent diffusion coefficient map showed a gyriform hypointense pattern. Prior outside magnetic resonance image obtained 1 day into the patient’s symptoms showed similar findings on T2/fluid-attenuated inversion recovery and T1 postgadolinium images but also gyriform hyperintensity on diffusion-weighted imaging, with hypointensity on apparent diffusion coefficient map in the same region. The patient was diagnosed with subacute cerebral infarction in the context of cardioembolic disease secondary to hereditary hypertrophic cardiomyopathy. As a result of the findings and diagnosis, the patient received an implantable cardioverter-defibrillator and was treated with warfarin, aiming for an international normalized ratio of 2.0 to 3.0 to reduce the risk of recurrent cardioembolic disease. The patient had a subacute ischemic stroke mimicking a brain mass radiologically. The acuity of symptom onset could have been a key clinical clue in this case but was absent from the patient history. Patients with stroke typically have hyperacute symptom onset (over seconds to minutes). Autoimmune and inflammatory central nervous system disease symptoms tend to have subacute evolution (over days to weeks) or might be chronic (over months).