Case Reports Neurosarcoidosis and Delirium J AMES A. B OURGEOIS , O.D., M.D., R ICHARD J. M ADDOCK , M.D. L ORI R OGERS , M.D., C LAUDIA M. G RECO , M.D. R AJESH S. M ANGRULKAR , M.D., S ANJAY S AINT , M.D., M.P.H. S arcoidosis is a systemic inflammatory disease with characteristic noncaseating granulomas. There may be involvement of multiple organ systems, including the lungs, lymph nodes, liver, skin, muscles, bones, and eyes. 1 Involvement of the nervous system (neurosarcoidosis) is seen in less than 10% of cases; psychiatric symptoms in- frequently herald disease onset. 1–3 Case Report Ms. A, a 39-year-old African American woman, came to a psychiatric hospital with incoherent speech, auditory hal- lucinations, and distractibility that had begun months ear- lier and worsened over 2 weeks. She had increased her long-term cocaine use and had unintentionally lost 70 kg in the last year. She was also a regular user of alcohol. She had no previous history of psychosis. After admission, she received oral risperidone, 2 mg b.i.d., without improve- ment. Four days later, she fell and suffered a right peri- orbital hematoma. For 2 days, she was nonverbal and re- fused food and drink. Ms. A was then sent to a university medical center, where computed tomography (CT) revealed a low-density area in her right frontal white matter. Subsequent magnetic resonance imaging (MRI) revealed a right frontal lobe en- hancing mass of 1.5 cm in diameter with surrounding Received March 12, 2004; revision received April 27, 2004; accepted June 15, 2004. From the Department of Psychiatry and Behavioral Sci- ences and the Department of Pathology/Neuropathology, University of California–Davis Medical Center; the Department of Veterans Affairs Health Services Research and Development Center of Excellence and the Department of Internal Medicine, University of Michigan, Ann Arbor. Address correspondence and reprint requests to Dr. Bourgeois, Depart- ment of Psychiatry and Behavioral Sciences, University of California– Davis Medical Center, 2230 Stockton Blvd., Sacramento, CA 95817; james.bourgeois@ucdmc.ucdavis.edu (e-mail). Copyright ᭧ 2005 The Academy of Psychosomatic Medicine. edema, multiple small enhancing lesions, and areas of edema within both cerebral hemispheres and posterior fossa structures and diffuse meningeal enhancement in both cerebral hemispheres, the cerebellum, and the brain- stem (Figure 1). Ms. A was admitted to the neurology service, and a psychiatric consultation was obtained. Psychiatric exami- nation findings included delusions; auditory hallucinations; thought disorganization; disorientation to person, place, and time; and stereotypical movements. Her risperidone dosage was increased to 1.5 mg q.i.d. CSF analysis re- vealed a glucose level of 27 mg/dl, a protein level of 166 mg/dl, 12 WBC/mm 3 , 1 RBC/mm 3 , and a negative Gram’s stain. Chest radiography and a CT showed bilateral hilar adenopathy and nodular pulmonary infiltrates. Intravenous dexamethasone and acyclovir were started for possible herpes simplex encephalitis. Tests for angio- tensin-converting enzyme, antinuclear antibody, human immunodeficiency virus, hepatitis B surface antigen, hep- atitis C antibody, and urinary histoplasmosis antigen were normal, as were VDRL results. A test for tuberculin-puri- fied protein derivative without controls was nonreactive. Polymerase chain reaction on CSF for mycobacterium tu- berculosis and herpes simplex virus types 1 and 2 were negative. Acyclovir was then discontinued. Tests for CSF cryptococcal antigen titer and acid-fast bacillus smear were negative, as were tests for CSF my- cobacterium, bacterial, and fungal cultures. Rifampin, ethambutol, isoniazid, pyrazinamide, and vitamin B6 were started for possible CNS tuberculosis. Psychiatry re-eval- uation on the eighth hospital day revealed full alertness and intact orientation but continued blunted affect and auditory hallucinations. Ms. A scored 14 on the Folstein Mini-Men- tal State Exam (MMSE). Her risperidone dosage was de- creased to 2 mg b.i.d. An open brain biopsy of the frontal lobe mass showed pale white, rubbery soft tissue that histologically revealed noncaseating granulomas with multinucleated giant cells Psychosomatics 46:2, March-April 2005 http://psy.psychiatryonline.org