Spinal neurosarcoidosis is uncommon and typically presents as LETM, a pattern that overlaps with neuromyelitis optica spectrum disorder and other inflammatory myelopathies, complicating diagnosis. MRI features such as dorsal subpial or pial enhancement—including the characteristic “trident sign”—may help differentiate sarcoid myelitis from other etiologies. Tissue confirmation of non-necrotizing granulomas remains essential and is most safely obtained from peripheral lymph nodes. High-dose corticosteroids are first-line therapy and often yield rapid improvement, while long-term agents such as methotrexate or TNF-α inhibitors (e.g., infliximab, adalimumab) are frequently required as maintenance therapy for disease control. Radiologic improvement may lag behind clinical response and often evolves over months to years. 

This case underscores the importance of considering neurosarcoidosis in patients presenting with unexplained vague symptoms and longitudinally extensive myelitis, especially when accompanied by pulmonary or lymphatic findings. Early recognition, biopsy confirmation, and prompt initiation of immunosuppressive therapy are critical for preventing irreversible neurologic deficits and achieving favorable clinical outcomes.