Isolated Aphasia as an Epileptic Manifestation of Neurosarcoidosis: A Case Report

Acute aphasia requires urgent evaluation for stroke, but recurrent and stereotyped language disturbances may also reflect focal seizures. We report the case of a 23-year-old man brought to the emergency department (ED) with aphasia that had been present for approximately six hours. Over the preceding week, he had experienced several similar but briefer episodes that had resolved spontaneously. He was concurrently undergoing investigation at another institution for persistent hiccups and near-daily vomiting of more than one month's duration. Chest computed tomography (CT) and positron emission tomography (PET)-computed tomography had already shown mediastinal and mesenteric lymphadenopathy suggestive of sarcoidosis, although other etiologies, including malignancy, could not be excluded. Neurological examination was limited by the language disturbance but showed no obvious motor deficit. Brain computed tomography revealed obstructive hydrocephalus with transependymal cerebrospinal fluid flow and multiple enhancing nodular lesions, predominantly in and around the ventricular system. Electroencephalography demonstrated epileptiform activity, and the aphasia resolved after treatment with levetiracetam and clobazam. Further cerebrospinal fluid analysis, magnetic resonance imaging (MRI), and pathological investigations supported a diagnosis of probable neurosarcoidosis presenting with lymphocytic meningoencephalitis and obstructive hydrocephalus. This case illustrates an unusual pathophysiological sequence, isolated aphasia as a focal epileptic manifestation of neurosarcoidosis, and is a reminder that unexplained focal neurological symptoms, particularly when fluctuating or recurrent, warrant the consideration of seizures and early electroencephalography.