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60 year old woman with sarcoidosis by mediastinal biopsy 1978 doing well, never requiring steroids. 2 mos prior developed SOB - smothering type of feeling even at rest but also on exertion. A CXR during a routine physical showed a left paralyzed hemidiaphragm.
Pmhx
sarcoid as above
NQWMI 1991 Echo on f/u showed torn chordae and LV "contractile abnormality" on a thallium test.
Three fluorouscopies revealed unilateral paralysis. Scheduled for EMG studies
Patient also adds:
"I am 60 y/o and live a quiet life but my legs are now getting weak and I am unable to bend down in a sitting position and get up. I failed to mention that I had a lumbar puncture which was normal. MRI showed cervical problems but nothing serious I guess. The pons area of my brain showed vascular changes due to aging. I also had strabismus during all of this and had a prism put in my glasses because of a convergence problem with my eyes. Could this all be connected? Myasthenia gravis I guess has been ruled out and they are calling this idiopathic phrenic nerve paralysis. Should I pursue this any further?I have about 40% function of my left lung."
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to sum up:
You have a lady with sarcoid (stable) for many years and now with new, multiple neurologic sx.
First a mononeuritis multiplex with unilateral diaphragmatic paralysis.
Second, strabismus (a second neuromuscular deficiency)
Third, pontine abnormalities on the MRI.
I doubt this is sarcoid. It is rare for sarcoidosis to present differently 30 years after the initial diagnosis. I think you are dealing with a new, neurologic problem.
Unfortunatly, from a pulm perspective, a MIP, MEP and MVV are probably not helpful given the diaphragm problem.
I would consider the following:
1. Neurology consult to r/o multiple sclerosis
2. Rheumatology serologies to w/u CVD
3. If the EMG is abnormal, you should do a muscle/sural nerve biopsy on the opposite side
4. Consider repeating the LP
I agree with Mike-- this is not from Sarcoidosis. Idiopathic phrenic nerve paralysis may be the eventual diagnosis, in which case there is a reasonable chance for recovery over time. I'm assuming that a chest CT was done and did not show any lesion in the mediastinum. If so, then I agree that a thourough neurologic evaluation is required. If the MRI was otherwise normal, and the LP is normal, then MS doesn't seem likely, however.
My diaphragm is still paralyzed after needle stimulation and EMG. My left hand and leg is starting to go into spasms and I have fallen asleep at my computer twice with a cup of coffee in my hands in the middle of the afternoon.
Please advise further.
See a neurologist
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