Abstract
Case Report A 29-year-old female presented with a 4-month history of right-sided hemifacial sensory disturbance. Examination revealed reduced pain and temperature sensation in the right V1, V2 and V3 regions and a diminished right corneal reflex. Past history included intermittent herpes labialis and travel to India twice in the prior 5 years.
Enhanced brain and skull-base magnetic resonance imaging (MRI) revealed enhancement at the cisternal segment of the right trigeminal nerve and right infraorbital nerve T2-hyperintensity. Diffuse extra-axial enhancement was noted in right Meckel’s cave, extending into the posterolateral cavernous sinus. Positron emission tomography (PET) imaging demonstrated markedly increased metabolism in the right Meckel’s cave and metabolism in the hilar and mediastinal lymph nodes consistent with sarcoidosis. Lymph node biopsies were inconclusive but revealed a possible granuloma. Right trigeminal nerve biopsy was subsequently performed. Histopathology revealed non-caseating granulomas with few acid-fast bacilli present. Primary neuritic leprosy was diagnosed and a 12-month treatment course of rifampicin, dapsone and clofazimine was commenced.
Repeat MRI 3-months post-treatment demonstrated reduced enhancement in the right cavernous sinus. Clinically her symptoms improved with antibacterial and steroid therapy. Repeat PET imaging revealed resolution of the Meckel’s cave changes but increased metabolism in thoracic and abdominal lymph nodes, raising the possibility of an alternative diagnosis (i.e. sarcoidosis) or dual pathology. Pregnancy halted further diagnostic work up.
This case highlights the complexities associated with diagnosing granulomatous disease even with access to multimodal imaging and biopsy sites, and the need to revisit the diagnosis if there are atypical features.
