Neurosarcoidosis-Induced Winging Scapula: Efficacy of Infliximab Treatment in Addressing Multifaceted Challenges.

Sarcoidosis, a systemic granulomatous disease primarily affecting the respiratory and lymphatic systems, can rarely manifest as neurosarcoidosis either in isolation or alongside other systemic symptoms. Here, we describe the case of a 45-year-old male with a history of recurrent sinusitis refractory to antibiotics, who presented to the emergency department with sinus congestion and dysphagia. Clinical examination revealed left lower motor neuron facial palsy and enlarged submandibular salivary glands. Despite obtaining negative results from various antibody panels, the patient exhibited elevated Angiotensin Converting Enzyme levels of 83 nmol/kg/min. Additionally, computed tomography chest scans revealed bilateral hilar and mediastinal lymph node enlargement, findings consistent with sarcoidosis. Otorhinolaryngology evaluation for dysphagia confirmed left vocal cord palsy. Following a negative infectious disease workup, submandibular salivary gland biopsy confirmed sarcoidosis. Treatment with mycophenolate mofetil and oral steroids led to gradual improvement in salivary gland swelling, dysphagia, and facial palsy. However, worsening left shoulder pain prompted further investigation, revealing winging of the left scapula on repeat examination. Magnetic resonance imaging (MRI) of the cervical spine revealed a six mm hyperintensity in the left dorsal cord at the C5 level, suggesting possible neurosarcoidosis vs. demyelinating disease. Subsequently, the patient was prescribed anti-tumor necrosis factor alpha inhibitor infliximab. Subsequent MRI of the cervical spine, conducted six months after initiating Infliximab therapy, indicated resolution of the lesions. This positive outcome was supported by the patient's report of symptom improvement, notably reduced shoulder pain and improvement in left scapular winging. This case underscores the unusual co-occurrence of Bell's palsy and vocal cord palsy in the same patient, along with the potential contribution of neurosarcoidosis to the winged scapula. Additionally, it sheds light on the positive response of neurosarcoidosis to Infliximab therapy.

A case of Helicobactor pylori negative low-grade gastric MALT lymphoma in an elderly female, successfully treated with rituximab.

PATIENT: Female, 91 FINAL DIAGNOSIS: Low-grade gastric MALT lymphoma Symptoms: Recurrent epigastric and right upper quadrant dyscomfort Medication: Rituximab Clinical Procedure: esophagogastroduodenoscopy • gastric biopsy Specialty: Gastroenterology. OBJECTIVE: Unusual or unexpected effect of treatment. BACKGROUND: Mucosa associated lymphoid tissue (MALT) lymphoma can occur in any extranodal organ or tissue, stomach being the common site. Most of the gastric MALT lymphomas are related to chronic H. pylori infection. H. pylori negative gastric MALT lymphoma is relatively uncommon and usually treated with a short course of chemotherapy, radiotherapy or surgery. CASE REPORT: Herein, we present a case of an elderly female with H. pylori negative, low-grade gastric MALT lymphoma that was successfully treated with a short course of rituximab. CONCLUSIONS: This case report emphasizes that rituximab monotherapy can be an effective treatment for H. pylori negative low grade gastric MALT lymphoma especially in an elderly patient where surgery or radiotherapy may not be appropriate.