Neurosarcoidosis: Diagnosis towards Clinical Insight
Dear Sir, We have read your impressive article "Neurosarcoidosis presenting as a large dural mass lesion" published in BMJ Case report on 8 November 2016. I have read about neurosarcoidosis thoroughly because of my previous exposure with few patients who were recovered as per diagnosis and prognosis.
First, your esteem has mentioned that the biopsy confirmed the diagnosis while the diagnosis of sarcoidosis depends on multiple factors. Infact, histopayhology is only one of the diagnostic steps that we totally agreed to be included in the investigative process but histopathological changes are non-specific because of unidentified molecular and cellular events. Indeed, Sarcoidosis has neither distinctive clinical features  exclusive changes in pulmonary function studies, diagnostic labarotary investigations, definite disease activity marker, special imaging findings nor specific histological picture.[4-6]
Consequently, the diagnosis of sarcoidosis is based on clinico- radiographic ?ndings which are supported by histologic evidence of the presence of noncaseating granulomatous in?ammation with the exclusion of similar presenting diseases such as tuberculosis, brucellosis, lymphoma, and lung cancer, autoimmunity disorders (primary biliary cirrhosis and Wegener's granulomatosis), drug reactions, occupational and environmental exposures (e.g. beryllium, talc), farmer's lung disease (hypersensitivity pneumonitis) and infections.[4-6]
So, when the diagnosis of sarcoidosis is considered, stains and culture for fungi and mycobacteria should always be obtained. Approching patient with sarcoidosis is based on the following criteria: 1) a compatible clinical and/or radiological picture; 2) histological evidence of non-caseating granulomas; and 3) exclusion of other diseases capable of producing a similar histological or clinical picture.
Second, your esteem has mentioned that your case has been treated with steroids and as you now there is no global / international consensus about the dose and duration. Most recommend prednisolone 20 - 40 mg for not less than 12 months.  While we have treated ourpatient with prednisolone tablet orally started with 40 mg daily in divided doses and tapered for as short as two months. We are egger to know what type of steroids you have prescribed and more importantly what was the dose and for how long was the treatment spectrum of this neurosarcoidosis case?
References 1. Baughman RP, Drent M, Kavuru M, Judson MA, Costabel U, Du BR, Albera C, Brutsche M, Davis G, Donohue JF, et al. In?iximab therapy in patients with chronic sarcoidosis and pulmonary involvement. Am J Respir Crit Care Med 2006;174:795-802. 2. Keir G, Wells AU. Assessing pulmonary disease and response to therapy: which test? Semin Respir Crit Care Med 2010;31:409-418. 3. Chesnutt AN. Enigmas in sarcoidosis. West j Med 1995; 162:519-526. 4. Nunes H, Bouvry D, Soler P, Valeyre D. Sarcoidosis. Orphanet J Rare Dis 2007; 2: 46. 5. Warshauer DM, Lee JKT. Imaging manifestations of abdominal sarcoidosis. AJR 2004; 182: 15-28. 6. Jundson MA. Sarcoidosis: clinical presentation, diagnosis and approach to treatment. Am J Med Sci 2008; 335: 26-33. 7. Iannuzzi MC, Rybicki BA, Teirstein AS. Sarcoidosis. N Engl J Med. 2007;357(21):2153-2165. 8. U. Costabel. Sarcoidosis: clinical update. Eur Respir J 2001; 18: Suppl. 32, 56s-68s. 9. Eishi Y, Suga M, Ishige I, Kobayashi D, Yamada T, Takemura T, Takizawa T, Koike M, Kudoh S, Costabel U, et al. Quantitative analysis of mycobacterial and propionibacterial DNA in lymph nodes of Japanese and European patients with sarcoidosis. J Clin Microbiol 2002;40(1):198-204.
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