Neurosarcoidosis, Coccidioidomycosis, or Both!

Area of Science:

• Ophthalmology
• Neurology
• Infectious Diseases

Background:

• This case report details a patient initially misdiagnosed with Coccidioidomycosis immitis (CI) infection.
• The patient presented with symptoms suggestive of ocular and neurological involvement.

Observation:

• A 57-year-old male presented with sudden vision loss, metamorphopsia, and color deficits in the left eye.
• Ophthalmic findings included optic disc edema and chorioretinal infiltration; MRI revealed orbital apex soft tissue abnormality.
• Initial diagnosis of CI meningitis was made based on positive serology, with partial response to antifungal therapy.

Findings:

• Orbital muscle biopsy revealed non-caseating granulomatous inflammation, prompting a trial of corticosteroids.
• Positron Emission Tomography (PET) CT confirmed sarcoidosis, leading to discontinuation of antifungals.
• Treatment with prednisone, methotrexate, and subsequently infliximab effectively managed ocular inflammation and neurological symptoms.

Implications:

• Neurosarcoidosis and Coccidioidomycosis can present with overlapping clinical features, necessitating careful differential diagnosis.
• Prompt and accurate diagnosis is crucial for initiating appropriate treatment and improving patient outcomes.
• This case underscores the importance of considering alternative diagnoses when initial treatments yield suboptimal results.