title: Isolated dysphagia unmasking bulbar neurosarcoidosis and pulmonary sarcoidosis.
abstract: Dysphagia is a rare manifestation of sarcoidosis. It is more commonly the result of esophageal compression by enlarged mediastinal lymph nodes rather than direct esophageal involvement and rarely secondary to neurosarcoidosis and oropharyngeal dysphagia. We report a 54 year old female presenting with a six month history of worsening dysphagia. She denied respiratory symptoms. Physical exam was normal. ESR was 61 mm/hr. Serum ACE level was 65 mcg/L. Chest X-ray was normal. Esophagram revealed a large amount of contrast pooling in pharyngeal recesses with intermittent laryngeal aspiration. Swallow videofluorography showed a decreased retraction of the base of the tongue, limited laryngeal elevation, and a large amount of contrast pooling in pharyngeal recesses with intermittent laryngeal aspiration. EGD showed a normal opening of the upper esophageal sphincter and the cricopharyngeus appeared normal. Proximal esophageal biopsies were normal. Brain MRI with gadolinium was normal. Lumbar puncture was performed. CSF showed a moderate pleocytosis, a WBC count of 19 with 97% lymphocytes, an elevated total protein level of 85 mg/dl (15-60). Neck CT scan showed no oropharyngeal tissue thickening or infiltration, no masses or enlarged lymph nodes. Chest CT scan showed enlarged intrathoracic lymph nodes and no esophageal compression. Bronchoscopy showed the vocal cords to be intact, and the CD4/CD8 ratio in BAL was 5.3. Subcarinal lymph node EBUS biopsy revealed non caseating granulomas. The patient was started on IV methylprednisolone. Three days later, the swallow videofluorography showed a near complete response to steroids. The patient tolerated regular consistency diet with thin liquids, and she was discharged on a slow taper of prednisone over a period of three months. A unique case of isolated dysphagia unmasking bulbar neurosarcoidosis and pulmonary sarcoidosis is herein reported.
authors.affiliation: Division of Pulmonary and Critical Care, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States. Electronic address: ana_tareck@hotmail.com.
authors.forename: Tarek
authors.initials: T
authors.lastname: Abdallah
authors.affiliation: Division of Pulmonary and Critical Care, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States.
authors.forename: Mokhtar
authors.initials: M
authors.lastname: Abdallah
authors.affiliation: Division of Pulmonary and Critical Care, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States.
authors.forename: Dany
authors.initials: D
authors.lastname: Elsayegh
authors.affiliation: Division of Pulmonary and Critical Care, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States.
authors.forename: Michel
authors.initials: M
authors.lastname: Chalhoub
authors.affiliation: Division of Pulmonary and Critical Care, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States.
authors.forename: Georges
authors.initials: G
authors.lastname: Khoueiry
authors.affiliation: Division of Pulmonary and Critical Care, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States.
authors.forename: Alex
authors.initials: A
authors.lastname: Glatman
authors.affiliation: Division of Pulmonary and Critical Care, Department of Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States.
authors.forename: Theodore
authors.initials: T
authors.lastname: Maniatis
mesh_terms: D002493:Central Nervous System Diseases / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D003680:Deglutition Disorders / Q000209:etiology*; D005260:Female; D005938:Glucocorticoids / Q000627:therapeutic use; D006099:Granuloma / Q000209:etiology / Q000473:pathology; D006801:Humans; D008198:Lymph Nodes; D008482:Mediastinum; D008775:Methylprednisolone / Q000627:therapeutic use; D008875:Middle Aged; D012507:Sarcoidosis / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy; D017565:Sarcoidosis, Pulmonary / Q000150:complications* / Q000175:diagnosis / Q000188:drug therapy
chemical_list: D005938:Glucocorticoids; D008775:Methylprednisolone
keywords: Dysphagia; EBUS; Neurosarcoidosis; Non caseating granulomas; Steroids