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Neurologic complications occur in approximately 5-16% of patients with sarcoidosis. Cranial neuropathies are the most common neurological presentation while neurosarcoidosis can also present with meningoencephalitis, seizures, and very rarely, a transient ischemic attack and stroke. Diagnosis can be challenging, and involvement of other organs may guide diagnostic approach. Here we present a patient with extensive nodular and painful tattoo reaction, who presented with acute onset neurological deficits and was subsequently diagnosed with neurosarcoidosis.

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A 36-year-old woman presented with sudden onset right eye blurry vision, dysarthria, right facial droop, and right-hand numbness. She saw a chiropractor the day prior for right sided neck pain and was being evaluated for intermittent joint and muscle pain with significant elevation in sedimentation rate. Physical exam was also notable for cutaneous nodules on the distribution of her tattoos over bilateral arms. Neurological symptoms resolved within an hour of onset. CT head and CT angiogram did not show any large territory infarct, hemorrhage, large vessel occlusion, or dissection. MRI brain with and without contrast revealed diffuse leptomeningeal enhancement. EEG was negative for epileptiform activity. CT chest revealed mediastinal and bilateral hilar lymphadenopathy. Serum and CSF ACE level were elevated. CSF analysis also showed normal glucose, elevated protein, and mononuclear pleocytosis. Hilar transbronchial biopsy exhibited non-necrotizing granulomas. Patient was diagnosed with neurosarcoidosis and treated with prednisone and methotrexate.

TIA is an extremely rare presentation of neurosarcoidosis; one case has been reported with recurrent TIAs and several cases of TIA that evolved to strokes. Here, we describe a patient presenting with TIA, whose physical exam revealed granulomatous tattoo reaction. While this cutaneous finding is a known but rare dermatological manifestation of sarcoidosis, it can serve as a guide to recognize neurosarcoidosis in patients presenting with primarily neurological symptoms.