Presentations

Abstract

Introduction: Sarcoidosis has been called "the great mimicker" [1]. Due to its nonspecific laboratory and imaging findings, it's essential to remember it is a rule out diagnosis. It is imperative to maintain a level of suspicion based on patient history to determine whether an underlying etiology for the granulomatous process can be established.

Case Information: We present the case of a previously healthy 24-year-old male welder who presented to an outside emergency department with one month of nonradiating upper and lower back pain, progressive lower extremity weakness, and muscle spasms necessitating the use of a walker beginning shortly after a minor workplace accident in which a plexiglass window fell on his helmeted head. Magnetic resonance imaging (MRI) revealed a disc herniation at the C6-C7 level with spinal cord compression with central/medullary hyperintensity extending from C2-3 to T4-5, leading to a finding of longitudinally extensive transverse myelitis (LETM). Incidentally, there were bilateral lung opacities and possible bilateral hilar lymphadenopathies. Findings were confirmed on chest computed tomography (CT) that showed bilateral hilar lymphadenopathy with multiple non-focal ground glass densities throughout both lung fields. The patient was transferred to our hospital, where he underwent anterior cervical discectomy and fusion (ACDF) of the C6-C7 spine. Neurosurgery noted extensive inflammation in the cervical spine, out of proportion to neck injury alone. No biopsies were taken due to high risk of further neurologic damage. Pulmonary was consulted for bronchoscopy and endobronchial ultrasound-guided (EBUS) bronchoscopy immediately following the ACDF. Bronchoalveolar lavage was significant for high lymphocyte count with multinucleated giant cells, normal CD4/CD8 ratio on flow cytometry, and the EBUS showed non-necrotizing granulomas and lymphocytes without evidence of malignancy. Blood work at the time of admission was notable for peripheral eosinophilia, elevated angiotensin-converting enzyme (ACE) level, and negative serum aquaporin-4 antibody. Heavy metal testing was remarkable for significantly elevated serum aluminum and minimally elevated serum copper levels, leading to a diagnosis of aluminum toxicity with pulmonary and neurological involvement. Despite successful cord decompression and disc fusion, MRI conducted 4 months postoperatively revealed persistent cervical spinal cord edema and lung opacities with bilateral hilar lymphadenopathy. Multiple attempts were made to see the patient in the clinic and start anti-inflammatory treatment, but the patient was lost to follow-up.

Discussion/Clinical Findings: LETM is typically associated with an autoimmune process, most commonly neuromyelitis optica [2], which was ruled out in our patient with his negative serum aquaporin-4 antibody. As a chronic granulomatous inflammatory disease, sarcoidosis can also induce LETM changes [3]. Bilateral hilar lymphadenopathies are the most common pulmonary sarcoidosis findings, while alveolar opacities are atypical [4]. ACE elevation is a nonspecific finding that is often associated with, but not limited to, sarcoidosis. Given the initial findings, it would be valid to conclude sarcoidosis as the correct diagnosis. However, given the patient's history as a welder, chemical related occupational lung disease was pursued and the underlying condition was determined. In this case, it would be essential for the patient to abstain from further welding work at the time of the diagnosis and would potentially be eligible for work-related compensation. These findings would not have been possible if the team settled on the diagnosis of sarcoidosis alone.

Conclusion: This is a case of a 24-year-old male with acute neurologic and pulmonary pathology likely due to chronic occupational aluminum inhalation. Cases such as this underscore the necessity of keeping a wide differential diagnosis when working up an unusual patient presentation and highlight the importance of proper protective equipment in careers such as welding and metalworking, where improper workplace safety practices can lead to detrimental health consequences.