A 45-year-male, presented with progressive cognitive decline in multiple domains over a 12 month period, he gradually developed impaired memory, psychomotor retardation, unsteadiness and falls. This accelerated prior to his admission when he became chair bound. He is known to have Ankylosing Spondylitis. He extensively travelled to Africa and South East Asia. On examination, he was emaciated; with an ACE-R of 20/100, the rest of his examination was normal. Investigations revealed lymphopenia, normal U&Es, LFTs, Bone profile, TFTs and vasculitis screen, serum ACE 26, CSF protein of 4.03 g, CSF glucose of 2 mmol/l with plasma glucose of 8.5 mmol/l and no cells. HIV, VDRL test were negative. Mantoux skin test was negative. Three early morning urine and sputum samples were negative for AAFB. Quantiferon test was indeterminate, while the T spot test was negative. MRI scan with Gad showed bilateral frontal white mater changes with asymmetric ventricular enlargement and meningeal enhancement. Chest HRCT showed apical pulmonary fibrosis due to Ankylosing spondylitis and active Sarcoidosis. Ophthalmology confirmed that he had iritis. Muscle biopsy was normal. Trans-bronchial biopsy showed non-caseating granulomas, highly suggestive of Sarcoidosis. The patient was treated with 1g IV Methylprednisolone for 3 days followed by oral 60mg prednisolone on daily basis. He showed dramatic recovery with his ACE-R scoring 44 and 78 on two consecutive weeks. The diagnosis in this patient was elusive, his past medical and travel history were misguiding. The case demonstrates Sarcoidosis as a cause of reversible dementia.
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