Amyotrophic Lateral Sclerosis developing in a patient with Chronic lymphocytic leukaemia and drug related a sarcoid-like reaction; teasing apart multiple diagnoses

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Abstract

Background Sarcoid-like reaction is an autoinflammatory disease that can affect lymph nodes and organs but does not meet the diagnostic criteria for systemic sarcoidosis. Anti-CD20 auto-antibodies have been reported to be responsible for such reactions. There are several reported associations between Chronic lymphocytic leukaemia (CLL) , Amyotrophic lateral sclerosis (ALS) and Sarcoid-like reactions. We report a case of ALS developing in a patient with CLL and drug related sarcoid-like reaction. Case presentation A 60-year-old male presented with lower limb rash, left leg weakness followed by bulbar symptoms which progressed over 12-months. Workup demonstrated a CSF pleocytosis and inguinal lymphadenopathy. Skin and inguinal lymph node biopsies showed non-necrotising granulomata. Electromyography met diagnostic criteria for ALS. He was treated for presumed neurosarcoidosis presenting with ALS. Despite treatment, the clinical course progressed like a classical ALS. Conclusion ALS may occur on a background of pre-existing chronic haematological disorders. Additionally, there is an occasional association of ALS and sarcoidosis. More interestingly, Rituximab can induce a sarcoid-like reaction.

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