Primary Neurosarcoidosis Mimicking Gallbladder Pathology

A 40-year-old African American male with long standing headaches and unintentional weight loss presented with nausea, vomiting, and blurry vision. Laboratory findings include hyponatremia and mildly raised liver enzymes. He underwent cholecystectomy six months prior for unexplained nausea and vomiting, which in hindsight was likely neurologic-induced vomiting from neurosarcoidosis. Brain imaging revealed diffuse, leptomeningeal, nodular enhancement involving the brain, brainstem, and upper cervical spinal cord. Further work up showed extensive lymphadenopathy above and below the diaphragm, solitary liver lesion, and multiple lytic lesions involving bones. Iliac spine biopsy revealed ill-defined, non-caseating granulomas with giant cell reaction infiltrating bone fragments. Acid-fast bacilli and fungal stains were negative. Patient was treated with steroids. Diagnosis of neurosarcoidosis is challenging in the absence of physical signs and symptoms. However, radiological and pathological correlation in clinical suspicion of sarcoidosis is helpful in more accurate diagnosis and timely management of the patient.