1. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. The Zebra of Bell’s Palsy Meets Sarcoidosis Gabriel T Gizaw,LT,MC,USN Curtis L Hardy,LT,MC,USN Michael R Wagner,CAPT,MC,USN 1

2. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Disclosures The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. 2

3. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Consent We obtained verbal informed consent from the patient for submission. 3

4. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Copyright: We are military service members. This work was prepared as part of our official duties. Title 17 U.S.C. 105 provides that 'Copyright protection under this title is not available for any work of the United States Government.' Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person's official duties. 4

5. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Introduction: Approach to general practice medicine in diagnosing pathology based on focus history and physical exam presentations. The Zebra may be pursued once common pathologies are eliminated and worked up. Sarcoidosis affects many young adults with incidence peaking between 20 – 40 years of age, commonly in the US among African Americans, Northern European Descendants, Asian and Puerto Ricans (1). 5

6. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Introduction Neurosarcoidosis (NS) as an initial presentation is relatively uncommon and occurs about 5% of the time in patients with sarcoidosis (2). Among the 5% presenting with NS, only 50%may present with neurologic symptoms when initially diagnosed (3,4,). Cranial Neuropathies are the most common presentation types of Neurosarcoidosis (5). 6

7. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Case Description A 39-year-old Hispanic male presents with a one-day history of right temporal headache that woke him from sleep. When he awoke for work and he noticed an inability to close his right eye, loss of taste sensation, difficulty chewing and drinking on the right side with slurring of speech. The patient denied any previous illness, no recent camping, no history of HSV, and no prior surgeries. 7

8. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Case Description Past medical history was positive for pre-hypertension. The review of symptoms and physical exam were negative except for his presenting symptoms and blood pressure of 154/100. A diagnosis of Bell’s palsy was made and he was treated with a tapering dose of Prednisone since onset of symptoms was less than seventy-two hours with a follow up for his blood pressure. 8

9. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Case Description Three weeks later the patient returns for a follow up evaluation. His facial weakness significantly improved. He had a new onset chief complaint of dysphagia and dysphonia. The patient reported a right mandibular neuropathic pain that was controlled with NSAIDs. 9

10. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Case Description A complete review of systems and physical exam was normal except those addressed at his presentation. There was a concern that his dysphagia and dysphonia might be secondary to his recent steroid use therefore a trial of PPI while waiting for ENT appointment. 10

11. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Case Description Three days later the patient returns with worsening dysphagia and dysphonia. His symptoms were more severe at night and he admitted to choking on food with difficulty clearing his throat. His voice was weak and harsh. As a result of worsening of his symptoms, he was scheduled to see ENT in several days. 11

12. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Case Description ENT evaluation with laryngoscopy confirmed complete vocal cord paralysis of the right vocal cord. He received collagen injection to right transverse vocal fold for closure of the vocal cord to prevent aspiration. Twenty-four hours later he had tachycardia of 110 measured and reported by the patient. 12

13. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Case Description Evaluation of the ECG revealed sinus tachycardia and CXR indicated prominence of the hila. CT of the chest indicated symmetric hilar and mediastina adenopathy with associated upper lobe pleural parenchymal thickening which favored stage 2 sarcoidosis. Serum Angiotensin Converting Enzyme was elevated at 68 nmol min -1 ml -1 with referral to Pulmonary for biopsy. MRI of the brain was negative. 13

14. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. 14

15. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Impression: Prominence of the hila as described. This can be seen with hilar adenopathy, or enlargement of the pulmonary vasculature favoring vascular process. This can be further evaluated by CT as clinically indicated. 15

16. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. 16

17. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Impression: Symmetric hilar, and mediastinal adenopathy with associated upper lobe pleural parenchymal thickening. This constellation of findings favors stage 2 sarcoid, however lymphoma cannot be excluded. 17

18. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Case Description While waiting for pulmonary biopsy, he presented with contralateral facial weakness. Patient diagnosed with Left Sided Bell’s Palsy and placed on Prednisone while waiting for his referral to Pulmonary Clinic. 18

19. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Case Description Pulmonary evaluation for Right hilar endobronchial US- Guided fine needle Aspiration indicated non-caseating granulomas in a background of lymphoid tissue without malignant cells. Mycology, gram stain and acid fast culture were negative. Sarcoidosis was diagnosed. 19

20. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Cytology of Non-Caseating granuloma 20

21. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. **This picture is not the patients but cytology report is** 21

22. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. A. LYMPH NODE, RIGHT HILAR, ENDOBRONCHIAL US-GUIDED FINE NEEDLE ASPIRATION: 22

23. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Discussion Isolated unilateral facial weakness is often secondary to idiopathic and consistent with Bell’s palsy. However when patients develop other cranial neuropathies, the need for the investigator to look for secondary causes become imperative. Consider Zebra pathologies as differential like Sarcoidosis, since facial nerve palsy may be caused by several pathologies. 23

24. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Discussion The treatment for Bell’s Palsy may mask the underlying pathology therefore follow up treatment after completion of prednisone therapy is essential to rule out extension of symptoms like dysphagia, dysphonia or other cranial nerve pathologies in our case report. Bilateral facial palsy has been reported with lyme disease but also one should consider the possibility of Sarcoidosis. This case represents neurological involvement of the multiple peripheral nerves of sarcoidosis (6). 24

25. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Discussion Sarcoidosis is primarily a diagnosis of exclusion. It may take several months before a unifying diagnosis can be made. The variable presentation and progressive nature of this disease often leads to a diagnostic delay by greater than six months (7). Our patient was diagnosed in one month. There is limited data on the prevalence among Hispanics and Latinos in the US (2). This requires more data. 25

26. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Reference 26 1. M ana JF, Badrinas F, Morera J, Fite E, Manresa F, Fernandez-Nogues F. Sarcoidosis in Spain. Sarcoidosis. 1992;9:118-122. American Thoracic Society. What is Sarcoidosis? American Journal of Respiratory and Critical Care Medicine. 2006; 173(P3-P4). 2. Burns TM. Neurosarcoidoisis. Arch Neurol 2003; 60:1166. 3. Dr J.P. Zajicek, Central nervous system sarcoidosis— diagnosis and management

27. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Reference 4. K, Tachibana T, Takemura T, Matsui Y, Kitaichi M, Kawabata Y. Pathological studies on sarcoidosis autopsy. 1. Epidemiological features of 320 cases in Japan. Acta Pathol Jpn 1993; 43:372–6. 5. Stern BJ, Krumholz A, Johns C, Scott P, Nissim J, Sarcoidosis and its neurological manifestations; Arch Neurol. 1985;42(9):909. 6. Vishal Jain, MD, Anagha Deshmukh, MD, and Stephen Gollomp, MD; Bilateral Facial Paralysis Case Presentation and Discussion of Differential Diagnosis; Diagnosis; J Gen Intern Med. Jul 2006; 21(7): C7–C10. doi: 10.1111/j.1525-1497.2006.00466.x 27

28. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. Reference 7. Judson, Marc A.; Thompson, Bruce W.; Rabin, David L.; Steimel, Joanne; Knattereud, Genell L.; Lackland, Daniel T.; Rose, Cecile; Rand, Cynthia S.; Baughman, Robert P.; Teirstein, Alvin S; The diagnostic pathway to sarcoidosis *. (Clinical investigations). Diagnosis Vishal 28

29. Vision: Naval Health Clinic Patuxent River will be an innovative leader in healthcare while ensuring optimal warrior readiness and family wellness. THANK YOU 29