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Obstructive hydrocephalus and progressive psychosis: rare presentations of neurosarcoidosis.
[hydrocephalus with stenosis of the aqueduct of sylvius]
Neurosarcoidosis
presents
with
meningitis
,
cranial
nerve
involvement
,
and
parenchymal
masses
.
Usually
,
abnormal
MR
enhancement
and
/
or
structural
lesion
(
s
)
are
present
.
Communicating
hydrocephalus
arises
from
meningeal
arachnoid
granulation
involvement
.
Reported
cases
of
obstructive
hydrocephalus
have
all
involved
obstructing
ventricular
lesions
.
A
40
-
year
-old
African
American
man
presented
with
papilledema
,
diplopia
,
and
headache
.
Magnetic
resonance
imaging
revealed
"
aqueductal
stenosis
"
without
abnormal
enhancement
or
obstructive
lesion
.
Although
symptoms
resolved
with
shunting
,
he
soon
developed
progressive
psychotic
symptoms
.
Serial
MR
scans
remained
free
of
abnormal
enhancement
or
structural
mass
lesion
(
s
)
but
revealed
long
repetition
time
and
proton
density
signal
changes
within
the
medial
temporal
lobe
structures
and
deep
white
matter
that
remained
stable
over
8
months
despite
clinical
progression
.
Serial
CSF
studies
were
nondiagnostic
.
Open
temporal
lobe
brain
and
meningeal
biopsy
revealed
noncaseating
granulomas
within
the
parenchyma
and
meninges
consistent
with
sarcoid
.
Total
-body
computed
tomography
scans
ruled
out
systemic
sarcoid
.
The
patient
steadily
improved
on
steroid
therapy
.
Neurosarcoid
psychiatric
symptoms
are
usually
associated
with
diffuse
meningeal
enhancement
from
meningitis
.
Our
case
reveals
that
absence
of
abnormal
enhancement
or
structural
mass
lesion
on
MR
and
normal
CSF
ACE
levels
do
not
rule
out
neurosarcoid
.
Based
on
a
patent
cerebral
aqueduct
and
the
T
2
MR
and
pathology
findings
,
we
postulate
that
altered
brain
tissue
compliance
with
impairment
of
normal
pulsatile
augmentation
of
aqueduct
CSF
flow
was
the
likely
cause
of
obstructive
hydrocephalus
.
This
represents
a
very
rare
psychiatric
presentation
and
reports
a
new
potential
mechanism
for
the
development
of
hydrocephalus
with
neurosarcoid
.
Diseases
Validation
Diseases presenting
"meningitis"
symptom
acute rheumatic fever
child syndrome
dracunculiasis
familial mediterranean fever
hydrocephalus with stenosis of the aqueduct of sylvius
kallmann syndrome
malignant atrophic papulosis
pyomyositis
scrub typhus
This symptom has already been validated