Carpal Tunnel Syndrome in Sarcoidosis: A Case Report of a Rare Neurologic Manifestation

Carpal Tunnel Syndrome in Sarcoidosis:  A Case Report of a Rare Neurologic Manifestation

 

Ajinkya Sonambekar, MD, MBBS; Nikhil Gupta, MD, MBBS;
Akanksha Swadi, MD, MBBS;
Laxmikant Ramkumarsingh Tomar, MD, MBBS

Perm J 2016 Fall;20(4):15-168

https://doi.org/10.7812/TPP/15-168
E-pub: 09/14/2016

ABSTRACT

Introduction: Sarcoidosis is a multisystemic inflammatory disease with myriad clinical manifestations. Neurologic involvement in sarcoidosis is uncommon. Peripheral neuropathic presentations include mononeuropathy, mononeuritis multiplex, and generalized sensory, motor, autonomic, and sensorimotor polyneuropathies.
Case Presentation: We report a case of carpal tunnel syndrome caused by sarcoidosis in a 30-year-old woman. Other causes of carpal tunnel syndrome were ruled out. The patient responded well to the standard line of corticosteroid treatment and wrist splinting.
Discussion: Carpal tunnel syndrome caused by sarcoidosis is a rare presentation. The mechanism of neurologic involvement in sarcoidosis is not clear.

INTRODUCTION

Neurologic involvement is reported in 5% to 10% of patients with sarcoidosis.1 Some authors consider neurosarcoidosis a totally different entity. Most often, a presentation of neurosarcoidosis is multiple fluctuating and remitting cranial nerve palsies. Noncranial neuropathy has been reported in 15% to 40% of cases of neurosarcoidosis.2 Scott et al3 reported a case series in which peripheral neuropathy developed in 6% to 18% of patients with neurosarcoidosis.

CASE PRESENTATION

A 30-year-old woman presented with complaints of tingling and numbness in her right hand. On detailed inquiry, the patient also had a history of malaise, anorexia, weight loss, and cough for 1 month. There was no associated muscular weakness of the right hand, fever, or any other systemic involvement. There was no history of tuberculosis. She was a nonsmoker and a nonalcoholic. Results of the physical examination revealed a positive Tinel sign. There was no skin lesion or lymphadenopathy. The systemic findings were normal.

The patient underwent many investigations (Table 1), of which relevant ones included a Mantoux test response of 0 mm at 48 hours and increased angiotensin-converting enzyme levels of 200 U/L. Fasting blood glucose level was 86 mg/dL, and the thyroid function test had a normal result. Nerve conduction studies showed carpal tunnel syndrome of the right hand with involvement of the sensory component without motor deficit. A chest computed tomography scan was obtained and showed right paratracheal and bilateral hilar lymphadenopathy, which was nonnecrotic without any calcification (Figure 1). A parenchymal lesion showed a reticulonodular pattern and suggested a diagnosis of sarcoidosis. Fine-needle aspiration cytology of the mediastinal lymph node showed noncaseating granulomas without any acid-fast bacilli and confirmed the diagnosis of sarcoidosis.
The patient was treated with corticosteroids, after which her symptoms of malaise, cough, anorexia, and weight loss subsided. Other causes of carpal tunnel syndrome were ruled out. A carpal tunnel splint was prescribed for the patient, after which she recovered.

Carpal Tunnel Syndrome in Sarcoidosis:  A Case Report of a Rare Neurologic Manifestation

Carpal Tunnel Syndrome in Sarcoidosis:  A Case Report of a Rare Neurologic Manifestation

DISCUSSION

This patient, who presented with neurologic complaints, turned out to have a case of neurosarcoidosis with carpal tunnel syndrome. Other common causes of carpal tunnel syndrome were ruled out on investigations.

The mechanism of neurologic involvement in sarcoidosis is not clear. Granulomatous inflammation of nerve layers, secondarily caused by vasculitic neuropathy, demyelination, panangiitis, compression by sarcoid tissue, or thick edema under perineural tissue are some of the proposed causes of nerve involvement in sarcoidosis.2 Treatment is mainly corticosteroid based and physical therapy. Our patient responded well to the standard line of treatment.

An association of carpal tunnel syndrome with sarcoidosis is rare, and our case adds to the existing sparse, English-language literature.2,4-6 The etiopathogenesis of carpal tunnel syndrome in sarcoidosis is not clearly defined. Thinking well beyond commonness may help in detecting the underlying cause of carpal tunnel syndrome, or else the diagnosis might be missed. Specific therapy in such cases may help in alleviating patient suffering and working toward the common goal of better patient care.

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

Acknowledgements

Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.

How to Cite this Article

Sonambekar A, Gupta N, Swadi A, Tomar LR. Carpal tunnel syndrome in sarcoidosis: A case report of a rare neurologic manifestation. Perm J 2016 Fall;20(4):15-168. DOI: https://doi.org/10.7812/TPP/15-158.

References
1.    Burns TM. Neurosarcoidosis. Arch Neurol 2003 Aug;60(8):1166-8. DOI: https://doi.org/10.1001/archneur.60.8.1166.
    2.    Nakatani-Enomoto S, Aizawa H, Koyama S, Kuroda K, Kimura T, Kikuchi K. Transient swelling of peripheral nerves in a case of neurosarcoidosis. Intern Med 2004 Nov;43(11):1078-81. DOI: https://doi.org/10.2169/internalmedicine.43.1078.
    3.    Scott TF. Neurosarcoidosis: progress and clinical aspects. Neurology 1993 Jan;43(1):8-12.
    4.    Niemer GW, Bolster MB, Buxbaum L, Judson MA. Carpal tunnel syndrome in sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dis 2001 Oct;18(3):296-300.
    5.    Yanardağ H, Pamuk ON, Kiziltan M, Yildiz H, Demirey S, Karayel T. An increased frequency of carpal tunnel syndrome in sarcoidosis. Results of a study based on nerve conduction study. Acta Medica (Hradec Kralove) 2003;46(4):201-4.
    6.    Shambaugh GE, Cirksena WJ, Newcomer KL. Carpal tunnel syndrome as manifestation of sarcoidosis. Arch Intern Med 1964 Dec;114:830-3. DOI: https://doi.org/10.1001/archinte.1964.03860120142018.

Subscriptions

The Permanente Journal (ISSN 1552-5767) is published quarterly by The Permanente Press. Journal subscriptions are entered for the calendar year. Advance payment in US dollars is required.

Circulation

25,000 print readers per quarter, 7,628 eTOC readers, and in 2016, 1.4 million page views on TPJ articles in PubMed from a broad international readership.

Letters

Articles, editorials, letters to the editor, and other material represent the opinion of the authors. Send your comments to permanente.journal@kp.org.


Copyright 2017 The Permanente Journal - Kaiser Permanente. All Rights Reserved.