Pearls & Oy-sters: Vocal Cord Palsy as the Presenting Manifestation of Neurosarcoidosis

Neurosarcoidosis poses a significant diagnostic challenge due to the diversity of presenting symptoms. We report a case of a 64-year-old woman with a history of hypertension and diabetes who presented with 3 weeks of progressive dysphonia and dysphagia. Initial differential diagnosis included myasthenia gravis, Guillain-Barré syndrome, infections such as syphilis or HIV, and neurosarcoidosis. Laryngoscopy and EMG demonstrated cranial nerve X and XII palsy. MRI brain was unrevealing, but a CT of the head and neck showed radiologic evidence of left vocal cord paralysis and asymmetric prominence of the left lingual tonsillar tissue. Her clinical findings, elevated CSF-ACE (angiotensin-converting enzyme) and CSF sIL-2R (soluble interleukin-2 receptor), and a previous thoracic tissue biopsy showing granulomas led to a 'probable' diagnosis of neurosarcoidosis after the thorough exclusion of other diagnoses. The patient was treated with pulse steroids and outpatient initiation of infliximab. There was prompt improvement in dysphagia and gradual amelioration of dysarthria and dysphonia. This case illustrates cranial nerve X and XII palsy as the presentation of neurosarcoidosis. In addition, it demonstrates the value of CSF sIL-2R as a biomarker for neurosarcoidosis and highlights the growing popularity of using steroid-sparing agents for treatment to achieve better outcomes with fewer side effects.