Noncaseating granulomatous disease involving the meninges: a case report

Rationale Multiple cranial nerve palsies can be a feature of infective, inflammatory and neoplastic processes. It is very important to differentiate between these conditions as the treatment is completely different. In the case that we are reporting, meningeal biopsy helped in revealing the diagnosis. Case Summary A 64 year old man presented with headache for 6 weeks, facial weakness for 3 weeks and swelling of the right eye with inability to move the right eye for 1 week. Our initial impression was cavernous sinus thrombosis, but the MRI brain did not show thrombosis of the cavernous sinus. Moreover there was thickening of the meninges on the MRI. As the patient had a history of myositis and pulmonary fibrosis and he had remained on steroids, we considered a septic or an autoimmune process. We empirically started steroids and antibiotics and the patient started to improve. However, to establish a diagnosis, we decided to go for a meningeal biopsy. It showed granulomatous inflammation and staining for infections and malignancies was negative. Considering his history of autoimmune disease and pulmonary fibrosis, we diagnosed him as a case of neurosarcoidosis and gave him high dose steroids and the patient improved. Conclusion Meningeal biopsy is helpful in establishing the diagnosis and to differential between infectious, inflammatory and neoplastic processes.