7.3.3 Headache attributed to other non-infectious inflammatory intracranial disease

Identification: Sex/Age: Male, 42 years

History: Pulmonary sarcoidosis diagnosed 2 years ago, on methotrexate 15mg/week

Current Medications: Methotrexate, folic acid

History of Present Illness (HPI): Main symptom: Holocranial headache for 3 weeks

Pain characteristics:

Onset: Gradual

Character: Constant pressure

Intensity: 6-7/10

Aggravation: Progressive worsening, no response to NSAIDs

Associated symptoms:

Intermittent double vision

Bilateral tinnitus

Weakness in the right lower limb

Relevant factors: History of sarcoidosis with possible CNS involvement

Physical/Neurological Examination: General: Preserved consciousness

Neurological:

Partial paralysis of the left sixth cranial nerve

Hypoesthesia in the right hemibody

Brisk reflexes in the right lower limb

Ataxic gait

Complementary Exams: Cranial MRI:

Granulomatous meningitis with leptomeningeal enhancement in the posterior fossa

Multiple periventricular parenchymal lesions

CSF:

Lymphocytosis (50 cells/mm³)

Elevated proteins (120 mg/dL)

Normal glucose

Elevated ACE (8.2 U/L)

Negative cultures

Laboratory:

Elevated serum ACE (65 ng/mL)

Elevated CRP and ESR