Steroid-unresponsive neurosarcoidosis successfully treated with adalimumab.

JO N 3077 with active interstitial lung disease. Bronchoalveolar lavage showed mixed inflammatory cells consistent with pulmonary inflammation. A diagnosis of probable sarcoidosis with pulmonary, neurological and opthalmological involvement was made based on the clinical, radiological and laboratory findings [1], and oral prednisolone (40 mg daily) was commenced. Despite initial improvement of the facial mononeuropathy, she developed weakness of the right arm and leg three months later while on prednisolone 35 mg once daily. Cervical spine MRI was normal as were repeat contrastenhanced MRI of brain and CSF examination. She improved substantially with intravenous methylprednisolone and oral steroids, but had persistent right hand clumsiness and mild right facial weakness. Nine months later, she developed worsening right arm and leg weakness, recurrent right facial droop, and tongue weakness over three days on oral prednisolone 15 mg once daily. Examination showed raised body mass index with cushingoid facies, right arm and leg hyper-reflexia, right arm and leg weakness (Medical Research Council grade 4/5), and a new left hypoglossal palsy. Repeat MRI showed basal meningeal enhancement with gadolinium. Following treatment with intravenous methylprednisolone, oral methotrexate (10 mg weekly) and hydroxychloroquine (200 mg daily) were added. Hydroxychloroquine was discontinued after two weeks due to severe alopecia. Following a further 10 weeks of treatment with methotrexate and prednisolone without clinical improvement, adalimumab was commenced (40 mg subcutaneously every other week). Within 1 month her tongue and limb weakness began to improve, with complete resolution of Michael Marnane Timothy Lynch Jacqueline Scott John Stack Peter J. Kelly