Neurosarcoidosis in Critical Care, Internal, and Pulmonary Medicine: A Practical Approach

Neurosarcoidosis is a rare but clinically significant manifestation of sarcoidosis, often presenting with diverse neurologic symptoms that can lead to permanent disability if left untreated. This review aims to provide internists, pulmonologists, nonneurologist clinicians, and critical care specialists with a structured, pragmatic approach to the evaluation, diagnosis, and management of neurosarcoidosis in two distinct patient groups: those with a known diagnosis of systemic sarcoidosis and those with no prior history of sarcoidosis. We emphasize the recognition of key acute clinical syndromes such as seizures, stroke, neuroendocrinopathy, hydrocephalus, meningeal disease, myelopathy, and infectious complications that may be encountered in emergency and critical care scenarios. The management approach, which includes first-line therapies such as glucocorticoids and immunomodulatory treatments such as TNF inhibitors and IL-6 inhibitors, is now accepted in the critical care setting to minimize the development of long-standing neurological complications associated with neurosarcoidosis. Furthermore, there is a critical need for a safe and effective transition to steroid-sparing medications for long-term disease control, while closely monitoring the risk for infections, such as tuberculosis and opportunistic infections, metabolic disturbances, and other complications. Given the significance of neurosarcoidosis as a severe manifestation of systemic sarcoidosis, a multidisciplinary approach is essential to effectively manage both neurological and systemic manifestations.