CNS involvement is often the initial manifestation of neurosarcoidosis; however, symptoms can be ambiguous, making a definitive diagnosis challenging.

Neurosarcoidosis presents with a range of symptoms, including seizures, cranial neuropathies, peripheral neuropathy, headache, and cognitive changes. This case report highlights a patient presenting with seizures who was ultimately diagnosed with neurosarcoidosis.

A 32-year-old African American male with a history of alcohol use disorder was brought to the emergency department after experiencing two episodes of generalized tonic-clonic seizures. Each episode was preceded by an aura characterized by dizziness and unusual smells, lasting 2–5 minutes, which were followed by postictal confusion and urinary incontinence.

The initial presentation was thought to be due to heat stroke; however, the patient was kept overnight for desaturation requiring oxygen support and was found to have leukocytosis. He was then admitted for further evaluation of seizures and probable pneumonitis. 

A routine EEG revealed right temporal spike-wave discharges and brief ictal rhythmic discharges (BIRDs), without evidence of clinical seizures. Subsequently, a brain MRI was obtained, which demonstrated a right temporal lobe, heterogeneous, enhancing cystic-solid infiltrative mass concerning for a glioma versus ganglioglioma. LP was performed revealing WBC 41 (with 50% segmented neutrophils), opening pressure of 25, and a total protein 177.

A brain biopsy was done and results revealed non-necrotizing perivascular granulomatous inflammation consistent with neurosarcoidosis. 

The patient was referred to the pulmonology clinic, where a CT scan showed subcentimeter mediastinal lymph nodes. He was started on infliximab, mycophenolate mofetil, and prednisone.